GASTROINTESTINAL NURSING

Digestive Tract Disorders

2015

The quality of our lives improves immensely when there is at least one other person who is willing to listen to our troubles.

—Mihaly Csikszentmihalyi

© Kagan Publishing

Anatomy and Physiology of the Digestive Tract

Mouth Where teeth, tongue, and salivary glands begin food digestion

Pharynx Muscular structure shared by the digestive and respiratory tracts It joins the mouth and nasal passages to the esophagus

Esophagus Long muscular tube that passes through the diaphragm into the

stomach

Stomach Churns and mixes food with gastric secretions until a semiliquid

mass called chyme

Anatomy and Physiology of the Digestive Tract

Small intestine Chemical digestion and absorption of nutrients

take place Approximately 20 feet long and consists of

three sections: the duodenum, the jejunum, and the ileum

Liver and pancreatic secretions enter the digestive tract in the duodenum

Anatomy and Physiology of the Digestive Tract

Large intestine and anus The first section of the large intestine is the cecum Ascending colon goes up right side of the

abdomen Transverse colon crosses abdomen just below

waist Descending colon goes down left side of abdomen The last 6 to 8 inches of the large intestine is the

rectum, which ends at the anus, where wastes leave the body

Age-Related Changes Teeth are mechanically worn down with age The jaw may be affected by osteoarthritis A significant loss of taste buds with age Xerostomia (dry mouth) is common Walls of esophagus and stomach thin with aging, and

secretions lessen Production of hydrochloric acid and digestive enzymes

decreases Gastric motor activity slows Movement of contents through the colon is slower Anal sphincter tone and strength decrease

Nursing Assessment and Health History ?? Common complaints of GI system Why is past medical history important?? What family history might be relevant?? What are some common questions you

need to ask in your review of systems???

Diagnostic Tests & Procedures

Gastrointestinal

System

Stool Specimens O&P OB Fecal Fat C & S

RADIOGRAPHIC TESTS Most common tests:

1) Barium swallow or UGI

2) Small Bowel series

3) Barium enema

Others: CTS,US abd. X-rays

ENDOSCOPIC TESTS (for upper GI system) Esophagoscopy Gastroscopy Gastroduodenoscopy EGD ERCP

ENDOSCOPIC TESTS ( for lower GI system)

Colonoscopy Proctoscopy Sigmoidoscopy

Laboratory Tests Gastric Analysis CBC PT (prothrombin time) INR PTT (partial thromboplastin

time)

Bilirubin Blood proteins Alkaline Phosphatase LDH GGT

AST ALT Cholesterol & Triglycerides Amylase CEA

Abnormal Assessment Findings Distention Firmness Tenderness Altered bowel sounds

Therapeutic Measures & Related Nursing Interventions

With GI Patients

Gavage or Enteral Nutrition (Tube Feedings) Provide nutritional support

through a tube Short or long term In conditions that prohibit

oral nourishment

Gastric Decompression Types of tubes ( pg. 780 ) What is the purpose of

gastric decompression? ??Nursing Interventions??

Types of Tubes Nasogastric - (NG) Gastrostomy – (G-tube) Jejunal – (J-tube) Percutaneous – (PEG)

Figure 38-6

Total Parenteral Nutrition – (TPN) Nutritionally complete Used when GI system not

functioning Short or long term

Figure 38-9

Critical Thinking Exercise A 71 y.o. woman who underwent a bowel

resection for the removal of a tumor is receiving TPN through a central venous catheter. The patient’s fingerstick blood glucose is 250 mg/dl, and the patient’s temp is 102 F and the nurse notes puralent drainage at the catheter insertion site.

Pre-Op Nursing Interventions

For GI surgery patients

GI tract cleansing Assess vital signs Liquids for 24 hrs. or NPO IV Antibiotics NGT insertion

Post-Op Nursing Interventions

For GI surgery patients

Relieve pain Detect complications Prevent gastric distention Replace lost fluids Maintain urine elimination

Digestive Disorders

Medical Anorexia Loss of Appetite Caused by:

Nausea, decreased sense of taste or smell, mouth disorders, and medications

Emotional problems such as anxiety, depression, or disturbing thoughts

Anorexia Medical diagnosis

Physician assesses for malnutrition Weight may be monitored over several weeks Complete history and physical examination Serum hemoglobin, iron, total iron-binding

capacity, transferrin, calcium, folate, B12, zinc

Thyroid function tests

Anorexia Assessment

Record chronic and recent illnesses, hospitalizations, medications, and allergies

Female patient’s obstetric history Symptoms: pain, nausea, dyspnea, extreme

fatigue The functional assessment reveals patterns of

activity and rest, usual dietary patterns, current stressors, and coping strategies—all can affect appetite

Anorexia Interventions

Assist with oral hygiene before and after meals Teach proper oral hygiene; refer for dental care Relieve nausea before presenting a meal tray Before serving meal tray, remove bedpans/emesis

basins from sight, conceal drains and drainage collection devices, deodorize room if necessary

Socialization during mealtime Respect food likes and dislikes Position patient comfortably with easy access to

food

Obesity 20% over ideal body wt. Morbid obesity= 2X

normal body wt.

http://www.medscape.com/features/slideshow/future-of-health/obesity?src=emailthis

Complications CV disease Diabetes Respiratory difficulties Musculoskeletal problems Emotional and social

isolation

Causes Caloric intake > expenditure Heredity Emotional stress/psychosocial

factors Slowed metabolism

Medical Management Weight reduction diet Exercise Medication Counseling

Surgical Treatment RNYGBP VBG LBP Liposuction Dumping Syndrome

Show what you know… List 3 Nursing Diagnosis & related

Nursing Interventions for the:

OBESE PATIENT

Disorders of the Mouth

Dental Caries Destructive process of tooth

decay Causes: Bacteria Poor oral hygiene

Prevention Frequent brushing and

flossing Dentist visit 2X/yr Good nutrition Fluoride

Treatment Removal of diseases

portion of tooth and filling May need dentures If untreated, may lead to

periodontal disease

Stomatitis Inflammation of the oral

mucosa Causes are??? Treatment is ??? What is Aphthous

Stomatitis?

Herpes Simplex HSV Type 1 Vesicles around the mouth &

lips Tx is comfort not curative Zovarax ointment (antiviral)

Candidiasis Fungal infection (Thrush) Candida Albicans White patches in mouth Immunosuppression Abx therapy

DISORDERS OF THE

TEETH & GUMS

Periodontal Disease Gingivitis(inflammation of

gums and supporting tissues) Gums are red, swollen,

painful and bleed easily Cause poor oral hygiene &

nutrition

SHOW WHAT YOU KNOW…

Assessment…?

Nursing Diagnosis….?

Interventions….?

Oral Cancer 2 types of malignant tumors Squamous and Basal cell Early s/s may be ignored Tongue irritation, loose teeth,

pain in ear or in tongue

Risk Factors Tobacco use Alcohol use Poor nutrition Chronic irritation http://www.oralcancerfoundation.org/

dental/slide_show.htm

Treatment

Chemo

Radiation

Surgery

Post Op Care Radical Neck Impaired oral mucous

membrane Ineffective breathing pattern Acute pain NGT, PEG, or TPN Disturbed Body Image

Disorders of Esophagus

Esophageal Cancer Not common, poor

prognosis Middle or lower portion of

esophagus No known cause

Predisposing Factors Cigarette smoking Excessive alcohol intake Poor oral hygiene Eating spicy foods

Signs and Symptoms Progressive dysphagia Weight loss may be dramatic TX Chemo or surgery Esophagectomy,

Esophagogastrostomy, or Esophagogastrectomy

Nursing Care of the patient with Esophageal CA Assessment….? Nursing Diagnosis….? Interventions….? Nutrition Anxiety Risk for infection, injury

Esophageal Diverticulum Esophageal out-pouching Zenker’s Diverticulum “Bad breath” due to

accumulation of food in diverticulum

http://en.wikipedia.org/wiki/Zenker's_diverticulum

Treatment Bland diet Antacids Anti-emetics Surgery

Pre-Op Nursing Measures Semi-fowlers Small meals Loose clothing

Disorders Affecting Digestion

And Absorption

Hiatal Hernia Protrusion of the lower

esophagus and stomach upward through the diaphragm

Two types: Sliding and Rolling

Causes Weakness of muscles of

diaphragm Exact cause is unknown Excessive intra-abdominal

pressure

Contributing Factors Obesity Pregnancy Abdominal tumors, ascites or

repeated heavy lifting

Signs and Symptoms Feeling of fullness Eructation Heartburn Dysphagia Regurgitation

Medical Treatment Avoid increased intra-

abdominal pressure HOB ^ 6-12 inchesprevents

nighttime reflux Drug Therapy Diet

Surgical Treatment Nissen Fundoplication Angelchik Prosthesis Figure 38-14 & 38-15

Nissen Fundoplication

THINK !! Describe your Post-Op Nrsg

Interventions for this patient?

GERD Gastroesophageal Reflux

Disease Backward flow of stomach

contents into the espohagus Sometimes occurs with a

sliding hiatal hernia

WHAT IS “NERD” ???

Signs & Symptoms Burning sensation that

moves up and down, commonly after meals

Intermittent dysphagia belching

Med Treatment & Nrsg Care Same as for hiatal hernia Drug therapy may include:

Zantac, Reglan, Prilosec & antacids

Fundoplication if required

Patient Teaching Avoid ASA and NSAIDS Chew food well Avoid eating 2 hrs. before

bedtime

Gastritis Inflammation of the stomach

mucosa/lining Several types; same

pathophysiology H-pylori prime culprit;

NSAIDS, stress, ETOH

Signs & Symptoms N/V Abdominal pain Anorexia Feeling of fullness

Treatment Meds Replacement of fluids after

N,V & diarrhea subsides Elimination of the cause Tx & nrsg. Interventions

same as for Ulcer Disease

THINK….. List 3 Nursing Diagnosis and related

interventions when caring for the patient with gastritis

What teaching would you do with this patient???

Peptic Ulcer Lesion on either the mucosa of

stomach or duodenum 80% are in duodenum May be acute or chronic Classified as gastric or duodenal See Table 38-4

Causes Bacterium H. pylori ASA, NSAIDS Physical trauma (shock,burns) Foods or conditions that cause

excessive gastric acid secretions

Comparison of Peptic Ulcers

GASTRIC Incidence

Ulcer depth

S/S

Complications

DUODENAL Incidence

Ulcer depth

S/S

Complications

Very Important Patient Teaching 1) Limit milk products

2) No baking soda

Complications of Peptic Ulcers

Hemorrhage Perforation Peritonitis Obstruction

Medical Treatment Drug therapy Diet therapy NGT hemorrhage Saline Lavage Surgical treatment options Table

38-6 Fig. 38-16

Complications after Gastrectomy Dumping syndrome pg. 813 Sx occur within 20 min of eating Bloating, flatulence, cramps &

diarrhea Diaphoresis, anxious, shaky Malabsorption--> Malnutrition

THINK… What teaching would you provide to the patient experiencing Dumping Syndrome??

Stomach Cancer “Silent neoplasm” Poor prognosis No early s/s Late s/s: vomiting, ascites,

abd. Mass, enlarged liver

Risk Factors H-pylori infection Pernicious anemia Chronic gastritis Family history

TreatmentChemoRadiationSurgery

Health Promotion Considerations What are some things we can do and or

teach others to do which might reduce the risk of developing several types of Cancer not just stomach Cancer???/

ABSORPTION & ELIMINATION

Disorders Affecting

Malabsorption Intestinal absorption of

nutrients is reduced Two examples are:

1) Celiac sprue/disease

2) Lactase deficiency

Signs & Symptoms Steatorrhea Malnutrition & weight loss Abdominal pain, cramping Bloating diarrhea

Treatment Sprue diet and drug

therapy, avoid foods w/ gluten(wheat, barley, oats)

Lactase avoid milk products & take lactase enzyme ( Lactaid)

Critical Thinking QuestionA nurse enters the room of a 72-year-old

patient who is receiving a continuous tube feeding and finds the patient lying flat in bed. The nurse questions the nurse assistant and discovers that the patient requested to be placed flat. What is significant about this situation? Why? How should the nurse handle the situation?

THAT’S IT…!!

YOUR DONE

WITH GI UNIT 1

ON TO UNIT 2…..