FOREWORD

Rachell Allen Professionals Academic Team is composed of clinical nurses,

nurse educators, and test prep experts that have studied the NCLEX-RN/PN

PRE LIVE COURSE

inside and out to provide you with the simplest and comprehensive review
course possible. Weve spent years refining our techniques for acing
standardized tests like the NCLEX-RN/PN.

WORKBOOK
The Pre Live Course Modules were developed to prepare you for the Live Course
part of your review. Here, we briefly review the concepts you will see on the
exam. These will structure your studying and reinforce each piece of
information with drills. Our goal is not to teach you the material, but to refresh
your memory of the concepts you learned in nursing school. More in-depth and
comprehensive discussions of these concepts will be done in the live lectures.

ALL THE BEST!

Recipe for success: Study while

others are sleeping; work while MODULE 5
others are loafing; prepare while
others are playing; and dream while THE GASTROINTESTINAL
others are wishing. SYSTEM
- David Bly
Review of Anatomy and Physiology
The gastrointestinal tract (GIT) consists of a hollow muscular tube starting from the oral cavity,
where food enters the mouth, continuing through the pharynx, esophagus, stomach and
intestines to the rectum and anus, where food is expelled. There are various accessory organs
that assist the tract by secreting enzymes to help break down food into its component
nutrients. Thus the salivary glands, liver, pancreas and gallbladder have important functions in
the digestive system. Label these parts on the picture below:

Assessment of the Gastrointestinal System

You need to know the four parts of the abdominal assessment for the NCLEX-RN. You should be
able to list them, in order:
1. ____________________
2. ____________________
3. ____________________
4. ____________________

Bowel sounds are considered absent if none are heard after auscultating for a minute or two in
each quadrant. In order to avoid stimulating bowel sounds, palpation is the last part of
abdominal assessment.

Diagnostic Studies
Certain diagnostic exams aid in gastrointestinal assessment. Match the following diagnostic
studies with the appropriate definitions:
 Column A Column B
1. ___ A flexible fiber-optic scope is used to visualize A. CAT scan
the entire colon B. endoscopic retrograde
2. ___ X-ray exam after oral ingestion of radiopaque dye cholangiopancreatography
to determine the patency of the biliary duct (E.R.C.P.)
3. ___ Percutaneous or intraoperative removal of hepatic C. fiber-optic
tissue to confirm diagnosis of hepatocellular diseases colonoscopy
4. ___ Noninvasive exam using sound waves to determine D. IV cholangiogram
organ size and shape E. liver biopsy
5. ___ Noninvasive radiological exam using tomography F. lower GI series (barium
to present organ structure at different depths and enema)
views; can be used with or without contrast G. oral cholecystogram
6. ___ Observation of contrast medium movement H. percutaneous
through the esophagus and into the stomach by means transhepatic cholangio-
of fluoroscopy and x-ray; the contrast dye can cause gram (P.T.C.)
impaction of stool so keep the client well hydrated; I. ultrasound
stool may be white for up to 2 days after the test J. upper GI endoscopy
7. ___ Radiological observation of contrast medium K. upper GI series
filling the colon (barium swallow)
8. ___ Flexible fiber-optic scope inserted into the mouth
and via the common bile duct and pancreatic
ducts to visualize these structures; after the test,
observe for hemorrhage
9. ___ Flexible fiber-optic endoscope that directly
visualizes the structures of the upper GI tract; after the
test, assess the clients gag reflex before allowing
PO intake
10. ___ Using fluoroscopy, the bile duct is entered
percutaneously and injected with dye to observe
filling of hepatic and biliary ducts; after the test,
observe for hemorrhage
11. ___ Radiographic exam used to visualize the biliary
duct system after intravenous injection of radio-
paque dye

The Mouth
Well start our review of the gastrointestinal system and its disorders with the mouth. To
review, fill in the blanks with words from the list below.

chemical starch
fifth starches
mechanical
Gastrointestinal structure and function begins in the mouth with 1.___________ and
2.___________ digestion. Much of the chewing process is innervated by the 3.___________
(trigeminal) cranial nerve. Salivary gland secretions begin basic 4.___________ digestion.
Salivary amylase begins the chemical breakdown of 5.___________ to maltose.

DISORDERS OF THE MOUTH

Match the abnormality of the lips, mouth, or gums listed in Column B with its associated
symptomatology listed in Column A.

Column A Column B
1. ___ Ulcerated and painful, white papules A. Actinic cheilitis
2. ___ Reddened area or rash associated with itching B. Leukoplakia
3. ___ Painful, inflamed, swollen gums C. Chancre
4. ___ White overgrowth of horny layer of epidermis D. Canker sore
5. ___ Shallow ulcer with a red border and white or yellow E. Gingivitis
6. ___ Hyperkeratotic white patches usually in buccal mucosa F. Lichen planus
7. ___ Reddened circumscribed lesion that ulcerates and G. Contact dermatitis
becomes encrusted H. Hairy leukoplakia
8. ___ White patches with rough, hairlike projections usually I. Stomatitis
found on the tongue
9. ___ Inflammation of the mucous lining of any of the
structures in the mouth

The Esophagus
Select words from the list below to fill in the blanks below:
belching peristalsis
esophageal sphincter swallowing
esophageal varices vomiting

The esophagus consists of muscular layers that contract and propel food into the stomach by
1.__________________. At the lower end of the esophagus is the 2.__________________,
which stays constricted except during 3.__________________, 4.__________________, and
5.__________________. Because the lower third of esophageal blood supply drains into the
portal system, portal hypertension may lead to the development of 6.___________________.

ESOPHAGEAL HERNIA
Select words from the list below to fill in the blanks below:
chest pain reflux
heartburn small, frequent meals
muscle weakening stomach

An esophageal hernia (hiatal hernia) is the herniation of a portion of the 1._______________

through an enlarged esophageal opening in the diaphragm. Factors that contribute to the
development of hiatal hernia (like all hernias) include 2._______________ and anything that
increases intra-abdominal pressure such as obesity, pregnancy, tumors, and ascites. The client
may be asymptomatic or have complaints of 3._______________ and 4._______________. The
client may also complain of 5._______________ while lying down. Any complaint of
6._______________ must be considered cardiac in origin until proven otherwise, so frequent
monitoring of vital signs is the nursing priority. In caring for the client with an esophageal
(hiatal) hernia, provide 7._______________ and maintain the client in an upright position
during and after meals to avoid regurgitation.

Medications commonly used to control symptoms caused by a hiatal hernia:

DRUG CLASSIFICATION DESIRED EFFECT
Aluminum Hydroxide 1. ____________________ Decrease heartburn
(Mylanta)
Magnesium Hydroxide
(Maalox)
Metoclopramide (Reglan) 2. ____________________ Improve gastric emptying

Ranitidine (Zantac) 3. ____________________ Decrease gastric acid

Famotidine (Pepcid) secretions
Cimetidine (Tagamet)

Omeprazole (Prilosec) 4. ____________________ Decrease gastric secretions

If reflux is severe, surgical repair may be performed. 5. _______________ involves wrapping

the fundus of the stomach around the lower portion of the esophagus to reduce the hernia
and tighten the sphincter.

ESOPHAGEAL NEOPLASMS
Esophageal neoplasms predominantly occur in clients with histories of hiatal hernia or alcohol
abuse. Clients present with a variety of upper gastrointestinal complaints such as pain,
dysphagia, nausea, and vomiting. The nurse must closely monitor the clients nutritional status.
The client should take in high-calorie and high-protein liquid supplements and vitamin and
mineral supplements. Parenteral nutrition either total parenteral nutrition (T.P.N.), via a
central venous catheter, or peripheral parenteral nutrition (P.P.N.) can be administered if
dysphagia is present. The choice of optimal nutrition is placement of a gastromy tube for
enteral feedings as soon as possible. This bypasses the affected area of the esophagus but uses
the functional stomach and intestines for digestion.

The following surgical procedures are commonly used to treat the client with esophageal
neoplasm. Test your ability to use the word to guide you to the definition.

Column A Column B
1. ___ Creating an opening through the abdominal A. esophagectomy
 wall and directly into the stomach into which a feeding B. esophagogastrectomy
tube is inserted to bypass the stomach. C. gastrostomy
2. ___ Removal of part or all of the esophagus, which
is replaced by a graft
3. ___ Resection of part of the esophagus and stomach;
the stomach is reconnected to the proximal end of the
esophagus

ESOPHAGEAL VARICES
Esophageal varices are blister-like spots in the esophagus caused by portal hypertension and
are often associated with liver cirrhosis (think cirrh-, liver; think osis, disease) and a history of
alcohol abuse. The client is usually asymptomatic until the varices rupture and bleed, so clients
who are known to have esophageal varices is a life-threatening event associated with a high
mortality rate.

Endoscopic sclerotherapy may be done prophylactically, therapeutically, or as an emergency

measure for esophageal varices. A sclerosing solution is injected into the varices to cause
thrombosis and stop the bleeding.

A Sengstaken-Blakemore tube may be used to mechanically control hemorrhage by balloon

tamponade. A client with a Sengstaken-Blakemore tube requires intensive care monitoring,
invasive hemodynamic monitoring, and intubation to protect her airway. Since the client is not
able to swallow around the tube, frequent mouth care and nutritional support are necessary.

Pharmacological therapy for esophageal varices may include administration of vitamin K,

vasopressin (Pitressin), and propranolol HCl (Inderal).

The Stomach

The stomach is a muscular organ located on the left side of the upper abdomen. The stomach
receives food from the esophagus. As food reaches the end of the esophagus, it enters the
stomach through a muscular valve called the lower esophageal sphincter.
The stomach secretes acid and enzymes that digest food. Ridges of muscle tissue called rugae
line the stomach. The stomach muscles contract periodically, churning food to enhance
digestion. The pyloric sphincter is a muscular valve that opens to allow food to pass from the
stomach to the small intestine.

GASTROESOPHAGEAL REFLUX DISEASE

Gastroesophageal reflux disease (G.E.R.D.) is the reflux of the stomach contents into the
1.__________, causing regurgitation, irritation, and heartburn.

Use your knowledge of G.E.R.D. to fill in the following blanks:

Instruct client to have small, frequent meals, a lot of liquids, and to avoid 2.__________,
3.__________, and 4.__________ in their diets. The client should be in an 5.__________
position during and after eating. The client should also be advised to avoid activity that
increases 6.__________ pressure. Pharmacological interventions include the use of
7.__________, and 8.__________, such as metoclopramide (Reglan).

GASTRITIS
Gastritis is an inflammation of the lining of the stomach, and has many possible causes. The
main acute causes are excessive alcohol consumption or prolonged use of nonsteroidal anti-
inflammatory drugs (also known as NSAIDs) such as aspirin or ibuprofen. Sometimes gastritis
develops after major surgery, traumatic injury, burns, or severe infections.

Do the following exercise to refresh your knowledge of gastritis. Gastritis may be caused by
which of the following?

A.___ cigarette smoking H.___chemotherapy

B.___ contaminated foods I.___ liver disease
C.___ hypertension J.___ C.N.S. lesions
D.___ alcohol K.___ steroids
E.___ low-fiber diet L.___ enteral feedings
F.___ caffeine M.___ intestinal obstruction
G.___ radiation therapy N.___ infection

PEPTIC ULCER DISEASE

A peptic ulcer, also known as peptic ulcer disease (PUD), is the most common ulcer of an area
of the gastrointestinal tract that is usually acidic and thus extremely painful. It is defined as
mucosal erosions equal to or greater than 0.5 cm. As many as 7090% of such ulcers are
associated with Helicobacter pylori, a helical-shaped bacterium that lives in the acidic
environment of the stomach; however, only 40% of those cases go to a doctor. Ulcers can also
be caused or worsened by drugs such as aspirin, ibuprofen, and other NSAIDs. Four times as
many peptic ulcers arise in the duodenumthe first part of the small intestine, just after the
stomachas in the stomach itself. About 4% of gastric ulcers are caused by a malignant tumor,
so multiple biopsies are needed to exclude cancer. Duodenal ulcers are generally benign.
 Differences Between Gastric and Duodenal Ulcers
Gastric Ulcers Duodenal Ulcers
Most common age Over 65 Under 65
Sex prevalence Female Male
Family history significant? Yes Not really
Risk factors Stress, smoking, alcohol C.O.P.D., chronic renal failure,
chronic pancreatitis, alcohol,
and cirrhosis
Location Stomach antrum Proximal 1-2 cm of the
duodenum
Clinical signs Upper abdominal pain 1-2 Upper abdominal pain 2-4
hours after meals; aggravated hours after meals; relieved by
by food food and antacids
Clinical course More likely to be chronic and Cyclical occurrences with
cause weight loss exacerbations and remissions;
causes weight gain
Cancer potential Increased malignancy Rare malignancy

Pharmacological therapy focuses on antacids, the drugs of choice for peptic ulcer disease.
Histamine blockers and anticholinergic drugs are used as well. Sucralfate (Carafate) is
prescribed for ulcer healing in the duodenum, as it coats the lining of the stomach to protect it
from irritation.

Foods that need to be avoided by clients with peptic ulcer disease include hot, spicy food;
alcohol; caffeine; and carbonated beverages.

Surgical intervention is warranted if the ulcer will not heal by conventional means. The goal of
surgery is to decrease stimuli for acid secretion, to decrease the number of acid secreting cells,
and to correct complications of peptic ulcer disease (which include bleeding).

Match the following procedures performed to manage peptic ulcer disease with the correct
definition below. Again, you do not need to memorize these procedures, just increase your
confidence in your ability to find the right answer with the information given:

Column A Column B
1. ___ Severance of the vague nerve, which eliminates A. Gastrojejunostomy
neural stimulation of acid secretion (Billroth II)
2. ___ surgical enlargement of the pyloric sphincter, B. Gastroduodenostomy
allowing easy passage of contents from the (Billroth I)
stomach C. Pyloroplasty
3. ___ Removal of most of the body and all of the antrum D. Subtotal gastrectomy
of the stomach E. Vagotomy
4. ___ Partial gastrectomy with removal of the distal
 2/3 of the stomach and anastomosis of the gastric
stump of the duodenum
5. ___ Partial gastrectomy with removal of the distal
2/3 of the stomach and anastomosis of the gastric
stump of the jejunum

A postoperative complication of gastric resection surgery is dumping syndrome. This is the

result of the stomachs loss of control over emptying its contents into the small intestine.
Dumping syndrome is generally self-limiting, resolving within one year of surgery. Nursing
interventions include monitoring for signs of dumping syndrome (palpitations, dizziness,
weakness, and abdominal cramping) and instructing the client to eat six small, dry feedings per
day that are moderately high in carbohydrates, low in refined sugar, and have a moderate-to-
high amount of protein and a moderate amount of fat. Carbonated beverages should be
avoided. Milk may not be well tolerated. The client should rest for at least 30 minutes following
meals. Fluids should be encouraged between meals.

The Gallbladder
The function of the gallbladder is to concentrate and store bile. The gallbladder contracts and
forces bile through the cystic duct into the common bile duct and, hence, into the duodenum.
The sphincter of Oddi regulates the one-way flow of bile into the duodenum.

CHOLECYSTITIS
Cholecystitis is inflammation of the gallbladder. In most cases, it is caused by gallstones that
block the tube leading out of your gallbladder. This results in a buildup of bile that can cause
inflammation. Other causes of cholecystitis include bile duct problems and tumors. If left
untreated, cholecystitis can lead to serious complications, such as a gallbladder that becomes
enlarged or that ruptures. Once diagnosed, cholecystitis requires a hospital stay. Treatment for
cholecystitis often eventually includes gallbladder removal, called cholecystectomy.

The Liver
The liver is a large, meaty organ that sits on the right side of the belly. Weighing about 3
pounds, the liver is reddish-brown in color and feels rubbery to the touch. Normally you can't
feel the liver, because it's protected by the rib cage. It has two large sections, called the right
and the left lobes. The gallbladder sits under the liver, along with parts of the pancreas and
intestines. The liver and these organs work together to digest, absorb, and process food.

The liver's main job is to filter the blood coming from the digestive tract, before passing it to
the rest of the body. The liver also detoxifies chemicals and metabolizes drugs. As it does so,
the liver secretes bile that ends up back in the intestines. The liver also makes proteins
important for blood clotting and other functions.

The liver is vital in sustaining life. Use the following chart to review the varied function of the
liver:

Manufacture Metabolize Store

Bile Carbohydrates Vitamins A, B, D
Fibrinogen Fat Iron
Prothrombin Protein Copper
Vitamin K Drugs and alcohol
Immunoglobins Hormones

HEPATITIS
Hepatitis, literally, is inflammation of the liver (hepat- = liver; -itis = inflammation). The
hepatitis virus invades, replicates, and causes damage in the liver. What happens when the
liver cannot perform the functions listed in the above chart? There are three phases of infection
with the hepatitis virus.

Phase 1: lasts 1-21 days; infectivity is at its height. Gastrointestinal symptoms dominate.
Phase 2: lasts 2-4 weeks. Symptoms are due to the spread of bilirubin through the
tissues: pruritis, dark urine, clay-colored stool, and jaundice.
Phase 3: lasts 2-4 months, jaundice resolves slowly. The client remains fatigued,
hepatomegaly persists.

There is no direct pharmacological treatment for viral hepatitis. Think about bleeding
precautions, gastrointestinal support, and client education. Supportive care is provided using
vitamin supplements, antiemetics are needed, symptomatic treatment of pain, and rest. The
client should be instructed in a proper diet of high-protein, high-calorie foods, and food with
low to moderate fat content as tolerated.
 Hepatitis Comparison Chart
Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E

(HAV) (HBV) (HCV) (HDV) (HEV)

What is it?

HAV is a virus HBV is a virus that HCV is a virus HDV is a virus HEV is a virus
that causes causes inflammation that causes that causes that causes
inflammation of of the liver. The virus inflammation of inflammation inflammation
the liver. It does can cause liver cell the liver. This of the liver. It of the liver. It
not lead to damage, leading to infection can only infects is rare in the
chronic disease. cirrhosis (scarring of lead to cirrhosis people with United
the liver) and cancer. and cancer. HBV. States. There
is no chronic
state.
Incubation period

15 to 50 days. 45 to 160 days. 2 to 25 weeks. 2 to 8 weeks. 2 to 9 weeks.

Average 30 days. Average 120 days. Average 7 to 9 Average 40
weeks. days.
How is it spread?

Transmitted by Contact with infected Contact with Contact with Transmitted

fecal/oral route, blood, seminal fluid, infected blood, infected through
through close vaginal secretions, contaminated IV blood, fecal/oral
person-to-person contaminated needles, razors contaminated route.
contact or needles, including and tattoo/body needles. Outbreaks
ingestion of tattoo/body piercing piercing tools. Sexual contact associated
contaminated tools. Infected mother Infected mother with HDV- with
food and water. to newborn. Human to newborn. infected contaminated
bite. Sexual contact. NOT easily person. water supply
spread through in other
sex. countries.
Symptoms

May have none. May have none. Some Even fewer Same as HBV. Same as HBV.
Adults may have people have mild flu- acute cases seen
light stools, dark like symptoms, dark than any other
urine, fatigue, urine, light stools, hepatitis.
fever and jaundice, fatigue and Otherwise same
jaundice fever. as HBV.
(yellowing of the
skin).
Treatment of chronic disease

No specific Interferon and anti- Interferon Interferon. Supportive.

treatment. virals. (peginteferon)
along with the
antiviral
ribavirin.
Vaccine

Two doses of At birth, a second None. HBV vaccine None.

vaccine, first dose between 1 and 2 prevents HDV
dose at 12 months, third dose infection.
months, second between 6 and 18
dose 6 months months.
later.
Who is at risk?

Household or Infant born to Anyone who had IV drug users, Travelers to

sexual contact infected mother, a blood men who developing
with an infected having sex with transfusion or have sex with countries,
person or living infected person or organ transplant men, dialysis especially
in an area with multiple partners, IV before 1992, patients, pregnant
HAV outbreak. drug users, health care healthcare women.
Travelers to emergency workers, IV drug workers,
developing responders, health users, dialysis infants born
countries, men care workers, men patients, infants to infected
who have sex who have sex with born to infected mothers and
with men and IV men, household mother and those having
and non-IV drug contacts of chronically having multiple sex with a
users. infected persons and sex partners. HDV infected
dialysis patients. person.
Prevention

Get a hepatitis A Get a hepatitis B Practice safe

Get a hepatitis Avoid
vaccine. vaccine. sex. B vaccine to drinking or
prevent HBV using
Take immune Take immune globulin Clean up spilled infection. potentially
globulin within within two weeks of blood with contaminated
two weeks of exposure. bleach. Wear Practice safe water.
exposure. gloves when sex.
Practice safe sex. touching blood. Wash your
Wash hands with hands with
soap and water Clean up infected Don't share soap and
 after going to the blood with bleach and razors or water after
toilet. wear protective toothbrushes. going to the
gloves. toilet.
Use household Don't inject
bleach to clean Don't share razors, street drugs.
surfaces toothbrushes or
contaminated needles. Don't get a
with feces, such tattoo or body
as changing Don't inject street piercing.
tables. drugs.

Practice safe sex. Don't get a tattoo or

body piercing.

CIRRHOSIS
Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue
by fibrosis, scar tissue and regenerative nodules (lumps that occur as a result of a process in
which damaged tissue is regenerated), leading to loss of liver function. Cirrhosis is most
commonly caused by alcoholism, hepatitis B and hepatitis C, and fatty liver disease, but has
many other possible causes. Some cases are idiopathic (i.e., of unknown cause). Cirrhosis is
generally irreversible, and treatment usually focuses on preventing progression and
complications. In advanced stages of cirrhosis the only option is a liver transplant.

Complications of cirrhosis include:

1. _______________ (fluid retention in the abdominal cavity) is the most common

complication of cirrhosis, and is associated with a poor quality of life, increased risk
of infection, and a poor long-term outcome.
2. _______________ (obstruction of normal blood flow through the portal and hepatic
veins causes hypertension in the portal venous system).
3. _______________ (blister-like spots) in the esophagus caused by portal
hypertension) Clients who are known to have esophageal varices must be
monitored for bleeding. The nurse should assess the client for melena stool,
tachycardia, and hematemesis. The rupture of esophageal varices is a life
threatening event associated with a high mortality rate.
4. _______________ (ammonia is a product of protein metabolism normally excreted
by the liver; because ammonia is shunted away from the liver, it stays in the
bloodstream and crosses into the brain, causing neurological deficits) Lactulose
(Cephulac) is the drug of choice as it binds with ammonia and is excreted in the
stool.
The Pancreas
The pancreas is a large gland located behind the stomach and next to the duodenum (the first
section of the small intestine). The pancreas has two primary functions:
1. To secrete powerful digestive enzymes into the small intestine to aid the digestion of
carbohydrates, proteins, and fat
2. To release the hormones insulin and glucagon into the bloodstream; these hormones
are involved in blood glucose metabolism, regulating how the body stores and uses food
for energy.
Match the following enzymes with the correct substance upon which they act:

Column A Column B
1. ___ Trypsinogen A. Carbohydrates
2. ___ Pancreatic amylase B. Fats
3. ___ Pancreatic lipase C. Protein

PANCREATITIS
Pancreatitis is a disease in which the pancreas becomes inflamed. Pancreatic damage occurs
when the digestive enzymes are activated before they are secreted into the duodenum and
begin attacking the pancreas.

Acute pancreatitis is a sudden inflammation that occurs over a short period of time. In the
majority of cases, acute pancreatitis is caused by gallstones or heavy alcohol use. Other causes
include medications, infections, trauma, metabolic disorders, and surgery. In up to 30% of
people with acute pancreatitis, the cause is unknown. The severity of acute pancreatitis may
range from mild abdominal discomfort to a severe, life-threatening illness. However, the
majority of people with acute pancreatitis recover completely after receiving the appropriate
treatment. In very severe cases, acute pancreatitis can result in bleeding into the gland, serious
tissue damage, infection, and cyst formation. Severe pancreatitis can also create conditions
which can harm other vital organs such as the heart, lungs, and kidneys.

Chronic pancreatitis occurs most commonly after an episode of acute pancreatitis and is the
result of ongoing inflammation of the pancreas. In about 45% of people, chronic pancreatitis is
caused by prolonged alcohol use. Other causes include gallstones, hereditary disorders of the
pancreas, cystic fibrosis, high triglycerides, and certain medicines. Damage to the pancreas
from excessive alcohol use may not cause symptoms for many years, but then the person may
suddenly develop severe pancreatitis symptoms, including severe pain and loss of pancreatic
function, resulting in digestion and blood sugar abnormalities

WHIPPLE OPERATION
Pancreatic cancer is an insidious disease that often goes undetected until its later stages. The
goal of treatment is frequently only palliative (to provide relief). If the tumor is less advanced,
the goal of treatment is curative. In either case, the treatment of choice is a whipple
procedure, the surgical intervention for pancreatic cancer. It may be combined with radiation
and/or chemotherapy.

Match the parts of a Whipple Operation in Column A with the explanations on Column B:

Column A Column B
1. ___ Proximal pancreatectomy A. Resection of the distal stomach
2. ___ Duodenectomy B. Resection of the duodenum
3. ___ Partial gastrectomy C. Resection of the proximal pancreas

The pancreatic duct, the common bile duct, and the stomach are reanastomosed to the
jejunum.

WHIPPLE PROCEDURE (PANCREATODUODENECTOMY)

In this technique, the doctor resects the stomach, duodenum, pancreas, and bile duct. The
doctor may also remove the gallbladder. Three anastomoses connect the common bile duct
proximal to the gastric anastomosis to neutralize acidic secretions dumped from the stomach
into the jejunum. A vagotomy to decrease gastric acid secretion may also be performed.

Dietary considerations after a whipple procedure include a low fat diet; small frequent meals;
and monitoring the clients blood sugar. Alcohol should be avoided.

The Small and Large Intestines

The intestines are a long, continuous tube running from the stomach to the anus. Most
absorption of nutrients and water happen in the intestines. The intestines include the small
intestine, large intestine, and rectum.

The small intestine has two primary functions: digestion and absorption of the end products of
digestion. The small intestine consists of the 1.________, 2.__________, and 3._________.
The most important functions of the large intestine are the absorption of water and
electrolytes, and the formation of feces for defecation. The large intestine consists of the
4.____________,5. _____________, 6.______________, 7.______________, and
8.____________.

The colon is divided into the 9.____________, 10._____________, and 11.___________ colon.

APPENDICITIS
Appendicitis is characterized by periumbilical pain followed by elevated temperature, anorexia,
nausea, and vomiting. The pain eventually localizes at 1.__________ point, between the
umbilicus and the right iliac crest. 2.__________ sign (palpation of the left lower quadrant of
the abdomen causes pain the right lower quadrant) is also present.

DIVERTICULA
Diverticula are out pouching of the intestinal mucosa through the smooth muscle of the
intestinal wall at any point in the gastrointestinal tract. They are most common in the sigmoid
colon. 1.__________ is the presence of multiple, noninflamed diverticula. Clients with
diverticulosis are often asymptomatic. A high fiber diet with a lot of liquid is recommended for
clients with diverticulosis. Seeds, nuts, and skins are usually restricted (while this is not
validated by studies, it is the conventional recommendation). 2.__________ is the inflammation
of diveticula and of the surrounding intestine, causing the tissue to become edematous.
Deficiency in dietary fiber has been associated with this condition. Complications of
diverticulitis are abscess and fistula formation; bleeding; bowel obstruction; and perforation,
causing peritonitis. The client with diverticulitis is usually NPO and is advanced slowly to clear
liquids and low-fiber to medium-high residue, and, finally, to a high-fiber diet, as tolerated.

CHRONS DISEASE AND ULCERATIVE COLITIS

Crohns disease and ulcerative colitis always appear on the NCLEX-RN. The following chart
summarizes what you need to know to answer these questions correctly.

Differences Ulcerative Colitis and Crohns Disease

Ulcerative Colitis Crohns disease
Age Any age; most common 10-50 Any age; most common 10-30
years old years old
Sex prevalence Women Women and men equally
Family history significant? Not really Yes
Area affected Beings in distal large intestine All layers of bowel wall, from
and moves up colon; mucosal mouth to the anus
and submucosal walls
Distributive Continuous ulceration Discontinuous ulceration
Clinical signs Frequent, bloody diarrhea, Nonspecific GI complaints, 3-4
abdominal pain semisoft stools/day
Cancer potential Increased malignancy No relation
The six goals of management of ulcerative colitis and Crohns disease are:
1. Control inflammation.
2. Correct metabolic and nutritional deficits. (Total pareneteral nutritional is a must! Usual
dietary progression is from bowel rest, NPO, to a low-fiber diet, to a regular diet, as
tolerated.)
3. Relieve symptoms.
4. Promote healing.
5. Combat infection.
6. Rest the bowel.

Emotional support and education are vital parts of nursing care for these clients, as these
conditions can alter lifestyle and body image perception.

Unlike ulcerative colitis, Chrons disease cannot be cured by surgical interventions. There is a
high recurrence rate after surgery. Surgical treatment depends on the affected area and on the
general condition of the client. The procedure of choice is conservative resection with
anastomosis of healthy bowel.

INTESTINAL OBSTRUCTIONS
Intestinal obstructions include anything that interferes with contents passing through the
gastrointestinal tract. The obstruction may be partial or complete. Intestinal obstructions will
manifest as abdominal distention and pain, and vomiting may contain fecal material. The nurse
must monitor the client closely for hyperactive bowel sounds and flatus. The client should also
be monitored for fluid and electrolyte imbalance and signs of dehydration. Decompression of
the intestine is accomplished using intestinal tubes such as the Cantor tube and the Miller-
Abbott tube that remove gas and fluid. Some mechanical obstructions are surgically relieved.

The client with an intestinal tube must be positioned on the right side to facilitate the passage
of the tube through the pylorus. After the tube passes the pylorus, the client is placed in a semi-
Fowlers position to continue the gradual advancement of the tube into the intestine.

COLON/RECTAL CANCER
Colon/rectal cancer is closely associated with the western diet which consists of foods high in
fat and low in fiber. The client is usually asymptomatic until the disease is well advanced. Occult
blood in the stool is an early indicator of colon cancer. Many rectal cancers are within reach of
the finger upon rectal examination.

Surgery is the only curative treatment of colorectal cancer. Following are the most common
surgical procedures performed. Match the procedure with the correct description below:

Column A Column B
1. ___ Used for cancer in the cecum, ascending A. Abdominal perineal resection
colon, hepatic flexure, or right transverse colon B. Left hemicolectomy
2. ___ Used for cancer in the left transverse colon, C. Low anterior resection
 splenic flexure, descending colon, sigmoid colon, D. Right hemicolectomy
or upper portion of the rectum
3. ___ Used for tumors of the rectosigmoid and
middle to upper rectum
4. ____ used for cancer located within 5 cm of the
anus (the proximal sigmoid colon is brought through
the abdominal wall to form a permanent colostomy;
the distal sigmoid, rectum, and anus are removed
through a perineal incision)

HEMORRHOIDS
Hemorrhoids are dilated varicose veins of the anus and rectum. They may be internal or
external. Internal haemorrhoids are the common cause of bleeding upon defecation and, over
time, can result in iron deficiency anemia. Causes of haemorrhoids include: pregnancy,
constipation, heavy lifting, and prolonged sitting. Treatment includes management of
constipation, diet management, and hemorrhoidectomy.

OSTOMIES
Teaching clients with ostomies and assessing ostomies are vital nursing functions.

Match the following types of ostomies with the correct definition:

Column A Column B
1. ___ Opening between the colon and the abdominal wall; A. colostomy
often used to temporarily rest the bowel. B. ileostomy
2. ___ Single stoma from the proximal end of the severed C. Kock pouch
colon with removal of the distal portion of the bowel. D. Loop colostomy
3. ___ Loop of bowel is brought out above the skin surface, E. permanent
where it is held in place by a plastic rod. colostomy
4. ___ Opening from the ileum through the abdominal wall;
most commonly used in the surgical treatment of ulcerative
colitis. Stool is like liquid. Dietary sodium should be increased
in these clients.
5. ___ Colectomy with creation of an internal pouch from the
ileum that has a nipple valve to control stool and flatus,
thereby maintaining continence; also known as continent
ileostomy.

Cients with ostomies may need to increase their fluid intake and avoid gas-producing
vegetables such as onions, beans, and cauliflower.
Disorders of the Abdominal Cavity
PERITONITIS
Peritonitis is the inflammation of the peritoneum. It is caused by infection (due to perforation)
and also by chemical stress, as in pancreatitis. The client will complain of abdominal pain,
elevated temperature, malaise, nausea, and vomiting. On examination, the nurse most often
finds rebound tenderness. Complete blood count shows an increase in white blood cells, as any
infection.

HERNIAS
Hernias are the protrusion of the intestine or abdominal organ through a weakening in the
abdominal wall (muscle). There are a variety of hernias that nurses encounter. Match the
specific hernia type with its clinical presentation:

Column A Column B
1. ___ Protrusion that cannot be replaced by manipulation A. femoral
2. ___ Protrusion through the site of an old surgical incision B. incarcerated
3. ___ Intestinal flow is completely obstructed C. inguinal
4. ___ Blood flow to the intestinal wall is completely obstructed D. irreducible
5. ___ Protrusion through the abdominal ring into the inguinal E. reducible
canal F. strangulated
6. ___ Protrusion through the umbilical ring G. umbilical
7. ___ Protrusion that can be replaced into the abdominal H. ventral
cavity by manipulation
8. ___ Protrusion through the femoral canal

Hernias can cause general gastrointestinal symptoms and intestinal obstruction. A binder may
be used to prevent strangulation. Surgical intervention may be necessary.

Gastrointestinal Surgery
In caring for the client after gastrointestinal surgery, the nurse encounters a variety of
postoperative drainage devices. Become familiar with them by matching the type of drain with
its use from the following list:

Column A Column B
1. ___ A collapsible device attached to a drain with A. Gastrostomy tube
multiple openings; exerts negative pressure to withdraw B. Hemovac self-suctioning
accumulated fluids device
2. ___ A nasogastric tube that has a second lumen for C. Jackson-Pratt
air entry that keeps the gastric lining from occluding the D. Jejunostomy tube
drainage holes; often attached to intermittent or low E. Levine tube
continuous suction; requires frequent irrigation to F. Penrose drain
maintain patency G. Salem sump
3. ___ The most common abdominal drain; flat, single H. T-tube
 lumen withdraws drainage by capillary action
4. ___ Oval, clear, pliable reservoir connected to drainage
tubing; reservoir or bulb can be compressed to form negative
pressure, often referred to as self-suction
5. ___ Single lumen nasogastric tube used to evacuate
air and fluid from the stomach; requires frequent
irrigation to maintain patency
6. ___ Tube that bypasses the stomach and allows for
feedings to maintain or restore a clients nutrition
7. ___ Tube that bypasses the esophagus and allows
for feeding to maintain or restore a clients nutrition
8. ___ Thin drainage catheter inserted into the common
bile duct during surgery to protect the suture line

Pharmacology for the Gastrointestinal System

There are few things more uncomfortable than a gastrointestinal issue, whether it's nausea,
diarrhea, or an ulcer. Thankfully, there are a variety of medications designed to treat these
problems.

Anticholinergics
Anticholinergic medications -- for example, dicyclomine -- slow the action of the bowel and
reduce the amount of stomach acid. Because these medications slow the action of the bowel by
relaxing the muscles and relieving spasms, they are said to have an antispasmodic action.

Antidiarrheals
Diarrhea may be caused by many conditions, including influenza (the flu) and ulcerative colitis,
and it can sometimes occur as a side effect of a medication. Narcotic drugs and anticholinergic
medications slow the action of the bowel and can thereby help alleviate diarrhea. An
antidiarrheal medication such as diphenoxylate and atropine combination contains both a
narcotic and an anticholinergic.

Antiemetics
Antiemetic medications reduce the urge to vomit. One of the most effective of these
medications is the phenothiazine derivative prochlorperazine. This medication acts on the
vomiting center in the brain. It is often administered rectally and usually alleviates nausea and
vomiting within a few minutes to an hour.

Other drugs that are used to combat nausea and vomiting include dolasetron, granisetron, and
ondansetron. Antihistamines are also often used to prevent nausea and vomiting, especially
when these problems are caused by motion sickness. This type of medication may also work on
the vomiting center in the brain.
Antiulcer Medications
Antiulcer medications are prescribed to relieve the symptoms and promote the healing of
peptic ulcers as well as to treat acid-reflux disease, which can cause severe heartburn pain in
some people. Histamine (H-2) blockers, including cimetidine, famotidine, nizatidine, and
ranitidine, work by preventing histamine from attaching to receptors on acid-secreting cells,
thus keeping the histamine from triggering the secretion of stomach acid.
Another group of antiulcer drugs are the proton pump inhibitors (PPIs); they limit stomach-acid
secretion by shutting down the acid pumps in the acid-secreting cells themselves. PPIs, which
include omeprazole, pantoprazole, and lansoprazole, are commonly prescribed to treat and
prevent many stomach problems. Another antiulcer drug, sucralfate, works by forming a
chemical barrier over an exposed ulcer that protects the ulcer from stomach acid, much as a
bandage protects a wound from debris. These medications provide sustained relief from ulcer
and heartburn pain and promote healing.

Laxatives promote the evacuation of stool. There is a risk of physical dependence, dehydration,
and electrolyte imbalance.

Match the type of laxative listed in Column C with its classification in Column B. Then match the
classification in Column B with its action listed in Column A.

Column A Column B Column C

1. ___ Magnesium ions alter stool consistency a. ___ Bulk forming I. Mineral Oil
2. ___ Surfactant action hydrate stool b. ___ Stimulant II. Metamucil
3. ___ Electrolytes induce diarrhea c. ___ Fecal softener III. Milk of magnesia
4. ___ Polysaccharides and cellulose mix with d. ___ Lubricant IV. Dulcolax
5. ___ Colon is irritated and sensory nerve e. ___ Saline agent V. Colace
intestinal content f. ___ Osmotic agent VI. Colyte
6. ___ Hydrocarbons soften fecal matter

Pancreatic enzymes are used to promote the digestion of proteins, fats, and starch. They
replace natural pancreatic enzymes (protease, lipase, amylase). Drugs in this category include
pancrelipase (Viokase) and pacreatin. They must be taken with food to minimize gastric
irritation.

NCLEX Type Questions

1. The nurse is teaching a parent whose (1) wearing a mask.
teenage son has hepatitis A. The nurse teaches (2) wearing gloves.
the mother that the best way to avoid spread (3) hand washing.
of infection is (4) wearing a gown.

2. Nursing care for a client with acute (1) a high-residue diet.

diverticulitis will include (2) bedrest and steroids.
(3) fluids by mouth and laxatives.
 (4) intravenous fluids and antibiotics.

3. A client has undergone an endoscopy of the (1) Administering analgesics for pain
upper gastrointestinal tract. The nursing care (2) Withholding food until a gag reflex is
plan should include which of the following? present
(3) Positioning the client on the right side
(4) Observing the client for rectal bleeding

4. A nurse develops a teaching plan for a client
diagnosed with hepatitis B. Which diet, when
selected by the client, would indicate the
teaching has been effective?
(1) Bacon, eggs, milk
(2) Shrimp, avocado salad, and skim milk
(3) Hamburger, cottage cheese, and malted
milk
(4) Carrots, lean beef, and orange juice

5. A nurse is to administer the hepatitis B
vaccine to a client. Which of the following
accurately describes the recommended dosing
interval for the hepatitis B vaccine?
(1) First dose followed by second dose 3
months later, followed by third dose 6 months
later.
(2) First dose followed by second dose 1
month later, followed by third dose 5 months
later.
(3) First dose followed by second dose 2
months later, followed by third dose 6 months
later.
(4) First dose followed by second dose 6
months later, followed by third dose 6 months
later.

6. The nurse is planning care for a client with (1) anticholinergics.

gastroesophageal reflux. Antacids are the first (2) antiemetics.
line of drugs used to treat this disorder, but if (3) calcium channel blockers.
these alone are not effective, the nurse may (4) histamine (H2) receptor antagonists.
notify the provider to add

7. A client with diagnosis of bleeding (1) Hypovolemic shock

esophageal varices must be observed for (2) Polycythemia vera
which of the following complications? (3) Hyperglycemia
(4) Abscess formation

8. The nurse is teaching a client about (1) Fleet enema.

treatment of haemorrhoids. In trying to help (2) hot packs.
the client be more comfortable, the nurse (3) stool softeners.
teaches nonsurgical treatments for (4) hemorrhoidoscopy.
haemorrhoids, which include
9. The nurse is caring for a client with a (1) most often a chronic ulcer.
duodenal ulcer. The nurse teaches the client (2) more likely to cause hemorrhage.
that a duodenal ulcer is (3) related to an increased risk of malignancy.
(4) likely to recur seasonally.

10. A 49-year old man with a duodenal ulcer is (1) Regular bland diet
admitted to the hospital when his hematocrit (2) Full liquid
was noted to be 18%. He is scheduled for (3) Regular pureed
emergency endoscopy. Which diet would be (4) NPO
appropriate?
 Bibliography
Bates B. A Guide to Physical Examination and History Taking, 5th ed. Philadelphia: JB Lippincott
Company, 1991

Beare PG. Davis NCLEX-RN Review. Philadelphia: FA Davis Company, 1991.

Black JM and Mantassarin-Jacobs E. Luckman and Sorensens Medical-Surgical Nursing, 4th ed.
Philadelphia: WB Saunders Company, 1994

Brunner and Suddarths Textbook of Medical-Surgical Nursing, 12th Edition, 2010

Clayman CB, ed. The American Medical Association Encyclopedia of Medicine. New York:
Random House, 1989

Evans MJ and Black MA. Surgical Nursing. Philadelphia: Springhouse Corporation, 1990

Fox SI. Human Physiology, 3rd ed. Iowa: William C. Brown Publishers, 1990

Goodner B. RN NCLEX Review Cards. El Paso, TX: SR Publishing, 1993

Lewis SM and Collier IC. Medical Surgical Nursing. 3rd ed. St. Louis: Mosby-Year Book, Inc., 1992

Malseed RT. Pharmacology Drug Therapy and Nursing Considerations, 3rd ed. Philadelphia: JB
Lippincott Company, 1990

McCance KL and Heuter SE. Pathophysiology. St. Louis: The CV Mosby Company, 1990.

Miller BF and Keane CB. Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health.
Philadelphia: WB Saunders Company, 1987

Nettina SM. The Lippincott Manual of Nursing Practice, 6 th ed. Philadelphia: Lippincott, 1996

Prentice Hall Nursing, Comprehensive Review for NCLEX-RN. Pearson Education, Inc., 2008

The Princeton Review Cracking the NCLEX-RN, 6th Edition, Princeton Review Publishing, 2001

Wilson JD, et al., eds. Harrisons Principles of Internal Medicine, 12th ed. New York: McGraw Hill,
1991