Gastrointestinal & Hepatic Disorders, Nursing Process, Community & Disaster Preparedness – Comprehensive Notes

Pyloric Stenosis

• Definition: hypertrophy of circular muscles of pyloric sphincter ➜ narrowing/stenosis of pyloric canal within first weeks of life.
• Classic triad
• Projectile vomiting immediately after feeding (sour-milk emesis, NO bile).
• Hunger/irritability, yet fails to thrive (FTT).
• Palpable “olive”-shaped epigastric mass + visible gastric peristalsis.
• Pre-operative management
• NPO, IV maintenance fluids & electrolyte re-balancing.
• NG tube for gastric decompression.
• Obtain serum electrolytes; correct metabolic alkalosis.
• Surgical cure: laparoscopic pyloromyotomy.
• Post-op nursing
• Fold diapers below incision to avoid contamination.
• Gradual feeds: start clear liquids, advance to formula/ breastmilk within 24 h; slow if vomiting.
• Burp well; position on right side to ↓ pressure on incision.
• NCLEX-style cues
• Parent will report baby “vomits forcefully then wants to eat again.”
• Pre-op care plan should include NPO, IV fluids, NGT on low suction (choice #2).

Cleft Lip & Cleft Palate

• Etiology: failure of maxillary processes to fuse in 1st trimester; multifactorial (environment, family hx, folic-acid deficit).
• Variants: unilateral / bilateral cleft lip; isolated or combined cleft palate.
• Pre-repair feeding
• Some breastfeed; use specialized squeeze bottles, long nipples.
• Upright position; aim nipple toward side/back of mouth.
• ESSR method: Enlarge nipple, Stimulate suck, allow Swallow, Rest.
• Burp frequently to avoid gastric distention.
• Surgical timelines
• Lip repair: 2–3 mo.
• Palate repair: 6–24 mo (ideal ≈ 18 mo).
• Psychosocial: provide parental emotional support; refer to Cleft Palate Foundation.
• Post-op Lip care
• Elbow restraints; no prone; maintain airway.
• Keep objects (straws, pacifiers, thermometers) out of mouth 7–10 days.
• Cleanse suture line after feeds; apply antibiotic ointment; watch for bleeding (excessive swallowing).
• Post-op Palate care
• May be prone.
• Liquids → soft diet until healed; no hard utensils.
• Elbow restraints, speech therapy, monitor otitis media risk (Eustachian tube dysfunction).

Esophageal Atresia (EA) & Tracheoesophageal Fistula (TEF)

• Embryology: failed separation of foregut ➜ blind esophageal pouch ± fistulous connection to trachea.
• Most common type: esophageal atresia with distal TEF (~85\text{–}88\%).
• Prenatal sign: polyhydramnios.
• Neonatal “3 C’s”: Coughing, Choking, Cyanosis with feeds + copious frothy secretions, abdominal distention.
• Pre-op nursing
• NPO, HOB ↑, continuous suction to pouch; O₂ & emergency equipment ready.
• IV hydration, ATBs.
• Parental education.
• Post-op
• TPN, ATBs; initiate oral feeds ≈ 1 wk.
• Teach signs of stricture, GER.

Hirschsprung Disease (Congenital Aganglionic Megacolon)

• Patho: absence of autonomic ganglion cells in distal colon ➜ internal sphincter cannot relax ➜ functional obstruction.
• Clinical
• Failure to pass meconium < 48 h.
• Abdominal distention, bilious vomiting.
• Chronic constipation, ribbon-like foul stools.
• Risk of enterocolitis (fever, pain, GI bleeding, explosive diarrhea) ➜ perforation.
• Diagnosis
• Barium enema: dilated proximal colon, narrow distal segment.
• Rectal biopsy = gold standard (no ganglion cells).
• Anorectal manometry: no relaxation of internal sphincter.
• Surgical
• Two-stage: temporary colostomy → pull-through at \approx20 lb.
• One-stage if early Dx.
• Nursing
• Pre-op: high-calorie/TPN, fluid-electrolyte balance, enemas/bowel prep.
• Post-op: I&O, stoma/wound care, pain, family teaching.

Intussusception

• Definition: telescoping of proximal bowel segment into distal → ischemia.
• Peak age 3 mo – 3 yr.
• Etiology: idiopathic, viral, or pathologic “lead point.”
• S/S
• Sudden severe colicky pain, knees-to-chest, periodic calm.
• Vomiting (may be bilious), sausage-shaped RUQ mass.
• “Currant-jelly” stools (blood + mucus), rectal bleeding.
• Progressive lethargy; risk of perforation, shock.
• Diagnosis/Treatment
• Abdominal X-ray to rule out perforation → therapeutic air/contrast enema.
• Surgery if enema fails or perforation.
• Monitor for recurrence (~8\%) & passage of normal brown stool (may indicate spontaneous reduction).

Celiac Disease (Gluten Enteropathy)

• Genetic autoimmune reaction to gliadin (component of gluten: wheat, rye, barley, oats).
• Patho cascade ➜ villous atrophy → malabsorption.
• Manifestations begin months after gluten intro:
• Steatorrhea (greasy, foul).
• Abdominal pain, vomiting, anemia, FTT; distended abdomen, wasted buttocks, thin limbs.
• Diagnosis: H&P, anti-gliadin/TTG antibodies, intestinal biopsy, response to gluten-free diet.
• Treatment: life-long gluten-free diet (corn & rice allowed); vitamin/mineral supplements ≥ 6 mo; adherence decreases GI cancer risk.

Viral & Non-Viral Hepatitis

• Definition: inflammatory liver injury disrupting vital functions.
• Viral types: HAV, HBV, HCV, HDV, HEV.
• HBV
• Transmission: blood, semen, vaginal fluids; perinatal.
• Vaccine (Recombivax HB, Engerix-B) series ×3 + HBIG post-exposure.
• Chronic infection possible; ↑ risk cirrhosis, HCC.
• HCV
• Transmission: blood > sexual; screen all adults (universal CDC guidance).
• >50\% chronic; leading indication liver transplant; no vaccine.
• Diagnosis: viral serologies (Lewis Table 48.6), LFTs (AST/ALT), bilirubin, PT.
• Chronic HBV Tx: nucleos(t)ide analogs ± interferon; goal ↓ viral load & progression, cannot eradicate virus.
• Chronic HCV Tx: direct-acting antivirals tailored to genotype; goal eradication.
• Health promotion: avoid body-fluid contact, safe sex, needle safety, vaccinations.

Autoimmune Hepatitis

• Chronic immune-mediated liver inflammation; often with other autoimmune disorders.
• Untreated ➜ chronic hepatitis → cirrhosis.
• Tx: prednisone ± azathioprine.

Non-Alcoholic Fatty Liver Disease (NAFLD) / NASH

• Spectrum: simple steatosis → non-alcoholic steatohepatitis (NASH) → cirrhosis.
• Occurs without significant EtOH use; risk factors = metabolic syndrome (obesity, DM, hyperlipidemia, HTN).
• Elevated ALT/AST common early clue; confirm with imaging; definitive Dx = liver biopsy.
• Management: weight loss, lifestyle change; no approved drugs (research evolving).

Cirrhosis

• Irreversible scarring replacing functional hepatocytes; leading cause = chronic alcohol; also HBV/HCV, NAFLD, drugs, biliary obstruction.
• Early findings: fatigue, hepatomegaly; later: portal hypertension & multisystem effects.
• Impaired functions
• ↓ Albumin → edema/ascites.
• ↓ Clotting factors → bleeding.
• Abnormal glucose metabolism.
• ↓ Bile → fat malabsorption, steatorrhea, vit K deficit, pruritus, clay stools, dark urine.
• Hormone imbalance → gynecomastia, menstrual changes.
• Portal HTN complications: ascites, splenomegaly, esophageal/gastric varices, hemorrhoids.
• Hepatic encephalopathy: ↑ ammonia → asterixis, cognitive change.
• Hepatorenal syndrome: renal failure due to altered hemodynamics.
• Labs: ↑ AST/ALT/ALP, ↑ bilirubin & PT/INR, ↓ albumin.

Chronic Pancreatitis

• Progressive fibrosis, calcification; major cause = chronic alcohol.
• Two types: obstructive (sphincter/ampullary) vs non-obstructive (alcohol-related, most common).
• Manifestations
• LUQ/epigastric pain radiating to back; heavy, gnawing, becomes constant.
• Malabsorption, weight loss, steatorrhea, mild jaundice, dark urine, constipation, diabetes.
• Complications: pseudocysts, biliary/duodenal obstruction, pancreatic ascites, pleural effusions, splenic vein thrombosis, pseudoaneurysm, cancer.
• Diagnostics: variable amylase/lipase, ↑ bilirubin & ALP, imaging (CT/MRI/MRCP, ERCP), stool fat, vitamin deficiency, secretin test.
• Management
• Pain control (morphine, fentanyl patch).
• Diet: bland, low-fat, small frequent meals; no alcohol/caffeine/tobacco.
• Pancreatic enzyme replacement with meals; monitor stool for efficacy.
• Bile salts, fat-soluble vitamins, DM management, acid reducers, antidepressants.
• Surgery/endoscopic drainage if obstruction/pseudocyst.
• Prognosis: ~66\% 10-yr survival; many require opioids long-term.

Nursing Process (ADPIE / AAPIE)

Assessment

• Systematic collection of objective (measurable) & subjective (patient-reported) data across physiologic, psychologic, social, cultural, spiritual realms.
• Techniques: interview, observation, inspection, auscultation, palpation, percussion; validate data.
• Example: “Pt nauseated” = subjective; VS, wound size = objective.

Diagnosis / Analysis

• Cluster cues → NANDA-I nursing diagnoses (actual, risk, wellness) using PES format:
• Problem related to Etiology as evidenced by S/S.
• Differentiate from medical diagnoses; identify collaborative problems & potential complications (PC).
• Formulation steps: highlight symptoms, list, cluster, interpret, choose label.

Planning

• Develop written care plan with goals (intent) & outcomes (measurable results); apply SMART criteria.
• Outcome components: Subject + Verb + Condition + Performance criteria + Time.

Implementation

• Execute interventions (direct & indirect); delegate, coordinate, educate; document care; remain accountable.

Evaluation

• Continuous assessment of outcome achievement; adjust care plan as needed.

Health & Wellness Concepts

• WHO: Health = complete physical, mental, social well-being.
• Health Belief Model: action likely if perceived susceptibility, seriousness, benefit > cost, cues to action, self-efficacy.
• Health Promotion vs Protection; Holistic models integrate body-mind.
• Prevention levels
• Primary: before disease (health promotion, immunization).
• Secondary: latent disease (screening).
• Tertiary: irreversible conditions (rehab, best management).

Community & Home Health Nursing

• Public health nursing targets populations; community health extends with organized initiatives.
• Community-based roles: advocate, educator, chronic-care manager, home health.
• Home health goal: promote/restore optimal function; consider health literacy.
• Levels of health care (preventive continuum) from outpatient risk control to inpatient tertiary management.

Emergency & Disaster Preparedness

• Emergency: extraordinary event manageable with local resources.
• Mass Casualty Incident (MCI): overwhelms local capacity; external aid required.
• Disaster triage (< 15 s per victim) color codes:
• Red = immediate life-threatening.
• Yellow = urgent, non-life-threatening.
• Green = minor.
• Black = deceased/expectant.
• Decontaminate if needed before transport; self-presenting “walking wounded” double first-hour numbers.
• CERTs (FEMA recognized) extend first responder capacity; focus on individual preparedness, basic rescue, safety.
• HCP responsibilities: know hospital incident plan, drill participation, interdisciplinary coordination.
• Federal resources: NIMS, FEMA, NDMS, American Red Cross.
• Psychologic stress universal; critical incident stress management essential.