Gastrointestinal system

Medical and Surgical Nursing

Gastro-intestinal Disorder

Prepared: Mark Fredderick Abejo RN, MAN

MS Abejo 1

MEDICAL AND SURGICAL NURSING

Gastrointestinal System

Lecturer: Mark Fredderick R. Abejo RN,MAN

______________________________________________________________________________________________

OVERVIEW OF THE STRUCTURE AND FUNCTION OF

THE GASTROINTESTINAL TRACT

I. UPPER ALIMENTARY CANAL (Digestion)

A. Mouth initial phase of digestion

B. Pharynx

C. Esophagus

D. Stomach complete digestion

E. First half of duodenum digestion

II. MIDDLE ALIMENTARY CANAL (Absorption)

A. 2nd half of duodenum

B. Jejunum

C. Ileum

D. 1st half of ascending colon




MS Abejo 2

III. LOWER ALIMENTARY CANAL (Elimination)

A. 2nd half of ascending colon

B. Transverse colon

C. Descending colon

D. Sigmoid colon

E. Rectum

IV. ACCESSORY ORGANS

A. Salivary glands – produces 1.2-1.5 L of saliva per day

1. Parotid – below and in front the ear

2. Sublingual

3. Submandibular

B. Vermiform appendix

C. Liver – largest gland, occupies most of R hypochondriac

region

1. Glison’s capsule – covers liver, transparent, brown

2. Liver lobules – functional site

D. Gall bladder

E. Pancreas

Small intestines – initial phase of absorption

Large intestines – absorption of vitamin K and complete phase

of absorption

Tears: lacrimal gland lacrimal duct lacrimal sac

punctae nasolacrimal gland

I. PAROTITIS (Endemic mumps) – inflammation of the parotid

gland

A. ETIOLOGIC AGENT

1. Paramyxovirus virus

B. SIGNS AND SYMPTOMS

1. Swollen parotid gland

2. Earache / otalgia

3. Dysphagia

4. Fever, chills, anorexia, generalized body malaise

C. NURSING MANAGEMENT

1. Strict isolation

2. Meds as ordered

Antipyretics

Antibiotics to prevent secondary infection

GENTIAN VIOLET HAS NO COOLING

EFFECT! Cooling effect may be caused

by vinegar!

Better to have mumps at an early stage,

preferably before puberty may lead to

sterility

3. Provide a general liquid to soft diet

4. Apply cold compress or ice pack at affected site

5. Prevent complications

Cervicitis, oophoritis, vaginitis

Meningitis

Orchitis sterility

II. APPENDECITIS – Inflammation of the vermiform appendix

(located at the R. iliac region, produces WBC during fetal life)

A. PREDISPOSING FACTORS

1. Microbial invasion

2. FECALITHS – undigested food particles (tomato,

guava seeds)

3. intestinal obstruction


1. (+) Rebound tenderness

2. Low grade fever, anorexia, nausea and vomiting

3. Pain at r iliac region

4. Diarrhea/constipation

5. Tachycardia d/t pain

C. DIAGNOSTICS

1. CBC – mild leukocytosis

2. PE – (+) rebound tenderness

3. Urinalysis – (+) acetone)

D. NURSING MANAGEMENT PRE-OP

1. Secure informed consent

2. Routinary nursing care

NPO

Skin preparation

Avoid enema may lead to rupture

3. Administer medications as ordered

antipyretics

antibiotics




MS Abejo 3

NO ANALGESICS! May mask pain which

indicates impending rupture

4. Monitor IO VS and Bowel sounds

5. Avoid heat application rupture

6. Maintain patent IV line

E. NURSING MANAGEMENT POST-OP

1. If (+) penrose drain (indicates rupture) – place

patient on affected site for drainage

2. If (-), position is based on pt. comfort


Analgesics

Antibiotics

Antipyretics PRN

4. Maintain patent IV line

5. Monitor VS IO and bowel sounds (N=borborygmi)

Complications: PERITONITIS AND SEPTICEMIA

MC BURNEY’S POINT – incision site for appendectomy

III. LIVER CIRRHOSIS (Laennec’s cirrhosis) – loss of

architectural design of liver leading to fat necrosis and

scarring; can lead to liver cancer


1. Alcoholism

2. Malnutrition

3. Viruses

4. Toxicity

Carbon tetrachloride

5. Use of hepatotoxic agent


1. Early

Weakness and fatigue

Anorexia

Nausea and vomiting

Tea-colored urine, clay-colored stool

Decreased sexual urge

Amenorrhea

Dyspepsia – indigestion

Hepatomegaly

Jaundice

Urticaria/pruritus

Loss of pubic/axillary hair

2. Late signs

Hematologic changes

Anemia

Leucopenia

Bleeding tendencies

Endocrine changes

Spider angiomas/ telangiectasis

Caput medusae (Varicose veins radiating

from the umbilicus)

Palmar erythema

Gynecomastia

GIT changes

Ascites

Bleeding esophageal varices d/t portal

HPN

Neuro changes

Hepatic encephalopathy

Early Asterixis (flapping hand

tremors)




MS Abejo 4

Late headache, dizziness,

confusion, irritability, fetor hepaticus,

(ammonia-like breath), decreased

LOC hepatic coma

C. DIAGNOSTICS

1. Liver enzymes

SGPT (ALT) elevated

SGOT (AST) elevated

2. Serum cholesterol

Ammonia elevated

3. Indirect bilirubin / Unconjugated bilirubin elevated

4. CBC low

5. PTT prolonged

6. Hepatic UTZ – fat necrosis of liver lobules

D. NURSING MANAGEMENT

1. Enforce CBR

2. Monitor strictly VS and IO

3. Weigh pt daily and assess for pitting edema

4. Measure abdominal girth and notify physician

5. Restrict Na and fluids

6. Diet high in CHO, moderate in fat, decreased

CHON, increased vitamins and minerals

7. Meticulous skin care


Ascites

Administer medications as ordered

Loop diuretics (Furosemide)

Assist in abdominal paracentesis

(empty the bladder pre-op)

Bleeding esophageal varices

Administer meds as ordered

Vitamin K

Pitressin (to conserve fluids)

Institute NGT decompression by gastric

lavage (ice/cold saline solution)

Assist in mechanical decompression –

insertion of sengstaken-blakemore catheter

( 3-lumen catheter) decompress

esophageal veins prevents bleeding

Hepatic Encephalopathy

Assist in mechanical ventilation

Monitor VS, NVS

Maintain side rails

Administer medications as ordered

Lactulose for ammonia excretion

PANCREAS Both an endocrine (islets of Langerhans) and exocrine gland

(Acinar cells)

IV. PANCREATITIS – an acute or chronic inflammation of the

pancreas leading to pancreatic edema, necrosis and

hemorrhage d/t autodigestion; idiopathic; TRYPSIN – kills

pancreas

A. PREDISPOSING FACTORS (na di hamak naman na

wala nito si Rico Yan)

1. Chronic alcoholism

2. Hepatobiliary disorders

3. Drugs:

Thiazide diuretics - Etacrynic acid Ano daw?

OCPs

Pentamide HCl (Pentam) – for AIDS

4. Metabolic disturbances

Hyperlipidemia

Hyperparathyroidism

5. Obesity

6. Diet: high in saturated fats

B. S/Sx

1. Severe abdominal pain radiating from the back (left

upper quadrant), chest and flank area accompanied

by DOB and aggravated by eating (so dapat naka

TPN to, uhm, usually an infusion vamine glucose or

lipofundin, kung may pera ang patient eh di

Nutripak; remember to keep all lines securely taped

to prevent embolism)

2. Shallow respirations

3. Tachycardia and palpitations, hypertension

4. Anorexia, N&V, dyspepsia

5. Decreased bowel sounds

6. (+) Cullen’s sign – ecchymoses around umbilicus

and (+) Grey-turner’s spots ecchymoses at the

flank area; both are indications of hemorrhage

C. DIAGNOSTICS

1. Serum amylase (very toxic to the body) and lipase

elevated

2. Serum Ca low (hypocalcemia)


1. Administer meds as ordered

Narcotic analgesics

Meperidine HCl (Demerol) Respiratory

Depression

DO NOT GIVE MORPHINE can

cause spasm of the sphincter of Oddi

Smooth muscle relaxation

Papanarine HCl

Vasodilators

NTG

Antacids (Maalox)

H2 receptor antagonist




MS Abejo 5

Ranitidine (Zantac)

Decrease pancreatic stimulation

Calcium gluconate

Phosphate binders

Amphogel

2. Withhold food and fluids (need to rest the GIT)

Nursing goal: rest the Git

Upon d/c: high CHO and CHON, low fat

3. Assist in TPN or hyperalimentation

Complications of TPN

Infection (so maintain strict asepsis)

Air embolism

Hyperglycemia

Hyponatremia

4. Instruct pt to assume comfortable position

Fetal position (knee-chest position)


Chronic hemorrhagic pancreatitis

Shock

Septicemia

6. Stress management

DBE, biofeedback

V. CHOLECYSTITIS/CHOLELITHIASIS – inflammation of

the gallbladder with gallstone formation


1. High risk group: women

2. Obesity

3. Post-menopausal women undergoing estrogen

therapy

4. Diet high in saturated fats

5. Sedentary lifestyle

6. Neoplasm

7. Obstruction


1. Severe abdominal pain (RUQ) radiating from the

back and chest that usually occurs at night

2. Fatty intolerance (pain after ingestion of high fat

meals) characterized by: Anorexia, nausea and

vomiting

3. Tea-colored urine and steatorrhea

C. DIAGNOSTICS

1. Gallbladder series (Oral cholecystogram) – confirm

presence of gallstones

2. Serum lipase elevated

3. Indirect bilirubin elevated

4. Alkaline phosphatase elevated

5. Transaminases elevated

D. NURSING MGT

1. Narcotic analgesics

Meperidine HCl (Demerol)

2. Anticholinergic agents

Atropine sulfate

3. Anti-emetics

Metoclopramide (Plasil)

Phenergan

4. Diet low in fat, high CHON and CHO

5. Meticulous skin care

6. Assist in surgery: Cholecystectomy

Post-op: maintain patency of tube drain (t-tube)

Monitor for infections

STOMACH J-shaped structure

Widest section of alimentary canal especially p.c.

A. Parts

1. Antrum

2. Fundus

3. Pylorus

B. Valves - prevents reflux

1. cardiac – between esophagus and stomach

2. pyloric – stomach and duodenum

projectile vomiting

olive shaped belly

C. Cells

1. Chief cells or zymogenic cells

Gastric amylase – digests CHO

Gastric lipase – digests fats

Pepsin – proteins

Rennin – milk and milk products

2. Parietal/augentaffin/oxyntic cells

Produces intrinsic factors reabsorption of B12

(cyanocobalamin) maturation of RBCs




MS Abejo 6

Produces HCl acid with pH of 1-2 aids in

digestion

3. Endocrine cells

Secretes gastrin stimulates HCl Acid secretion

D. FUNCTIONS

1. Mechanical and chemical digestion

2. Storage of food

CHO and CHON – 1-2 hours

Fats – 2-3 hours

V. PEPTIC ULCER DISEASE – erosion/excoriation of

submucosa/mucosal lining d/t

Hypersecretion of acid – pepsin

Decreased resistance of mucosal barrier to HCl

acid secretion (neutralizes acidity)

A. INCIDENCE RATE

1. Men

2. Aggressive

B. PREDISPOSING FACTORS

1. Heredity

2. Emotional stress

3. Smoking vasoconstriction gastric ischemia

4. Alcoholism release of histamine parietal cells

to secrete gastrin

5. Irregular diet

6. Rapid eating

7. Ulcerogenic drugs

Aspirin

Ibuprofen

Indomethacin (SE:corneal cloudiness)

Steroids

NSAIDs

8. Foods or beverages rich in caffeine

9. Gastrin producing tumors

Gastrinoma Zollinger-Ellison’s Syndrome

10. Microbial invasion (Helicobacter pylori)

Metronidazole

SE: photosensitivity

Etampicillin

C. TYPES

1. Severity

Acute ulcers – submucosal

Chronic ulcers – deeper underlying tissues; (+)

scar formation

2. Location

Stress (Critically-ill patients)

Curling’s ulcer

Burns and trauma hypovolemia

GIT ischemia decreased resistance

of mucosal barrier to HCl acid

secretion

Cushing’s ulcer

Head trauma

CVA/Stroke increased vagal

stimulation hyperacidity

ulceration

Gastric

Duodenal

Differences Gastric Ulcer Duodenal Ulcer (90%)

Location Antrum Duodenal bulb

Pain 30 mins-1hour p.c. 2-3 hours p.c.

12mn-3am pain

Pain location Epigastrium Mid-epigastrium

Pain

character

Gaseous and burning, not

relieved by food and

antacids

Cramping and burping,

relieved by food and

antacids

Gastric acid

secretion

Normal Increased

Weight Loss Gain

Hemorrhage Hematemesis Melena

Complication

s

Hemorrhage, stomach

cancer

Perforation

High risk 60 y.o above 20 y.o above

D. DIAGNOSTICS

1. Endoscopy

2. (+) Stool occult blood

3. Gastric analysis reveals

Normal gastric acid secretion if gastric

Increased gastric acid secretion if duodenal

4. Upper GI series – confirms ulceration

E. NURSING MANAGEMENT (Diet, Drugs, Surgery)

1. Bland diet non-irritating, non-spicy

Avoid beverages and foods high in caffeine or

milk and milk containing products

2. Admin meds as ordered

Antacids

ACA – aluminum containing antacids

Aluminum OH gel (Ampho gel)

SE: constipation, hyperphosphatemia,

hypoparathyroidism

MAD – magnesium containing antacids

Milk of magnesia

SE: diarrhea

Mg + Al preparations (Maalox) less SE

H2 receptor antagonists




MS Abejo 7

Cimetidine (Tagamet) – antagonizes oral

anti-coagulant, more SEs

Ranitidine (Zantac) – most common,

fewer SE

Famotidine (Pepsid)

Give antacids and Cimetidine ONE

HOUR APART decreased antacid

absorption and vise versa

Instruct client to avoid smoking because it

decreases effectiveness of drug

Cytoprotective agents

Sucralfate (Carafate) provides a paste-

like substance that coats the mucosal

lining

Cytotec (Misoprostol) causes severe

spasm (abortifacient) uterine cramping

bleeding

Anticholinergic/Anti-spasmodic agents

Atropine

Propanthelene sulfate (Probanthene)

Sedatives, tranquilizers

3. Assist in surgical procedure: subtotal gastrectomy

Billroth I (removal of 1/3 of stomach)

Gastroduodenostomy gastric stump to

the duodenum

Billroth II

Gastrojejunostomy gastric stump to

jejunum

Removal of ½ to ¾ of the stomach,

duodenal valve and anastomosis of gastric

stump to jejunum

Complic: DUMPING SYNDROME

Vagotomy (severe vagus nerve) and

pyloroplasty for drainage

Decrease vagal stimulation decrease

HCl acid secretion prevent hemorrhage

F. NURSING MANAGEMENT POST OP

1. Monitor NGT output that includes:

Immediately after post-op bright red

32-46 hours greenish in color

48h dark red because of influence of HCl

acid


Antimicrobials

Narcotic analgesics

Anti-emetics

3. Maintain a patent IV line

4. Monitor VS, IO, Bowel Sounds

5. Prevent complication

Hemorrhage shock

Paralytic Ileus – most common type of

complication in all abdominal surgery

Peritonitis

Septicemia

Hypokalemia

Pernicious anemia

DUMPING SYNDROME (Billroth II) – rapid

emptying of hypertonic food solutions; chyme

– food and HCl acid from stomach to jejunum

with resultant hypovolemia dizziness,

diaphoresis, palpitation, tachycardia, diarrhea,

weakness

Nursing management for dumping

syndrome:

Provide fluids BEFORE meals

Avoid fluids/chilled solutions

Provide a small frequent feeding or 6

equal divided feeding

Diet low in CHO and sugar moderate

CHON and fats

Instruct pt to lie flat on bed 15-30

minutes after each feeding




MS Abejo 8

VI. DIVERTICULUM – outpouching of the intestinal mucosa

particularly the sigmoid colon; DIVERTICULOSIS –

multiple diverticulum; DIVERTICULITIS – inflammation of

diverticula


1. High risk: female

2. Congenital weakness of muscular fibers of intestines

3. Obesity

4. Stress

5. Diet: decrease in roughage


1. Intermittent pain at LLQ and tenderness at the

rectosigmoid area

2. Alternate bouts of diarrhea/constipation with blood

and mucosa

3. Decreased hematocrit/hemoglobin amnesia

C. DIAGNOSTICS

1. Barium Enema – reveals inflammatory process

2. Decreased hematocrit/hemoglobin (d/t diarrhea)


1. Administer medications as ordered.

Bulk laxatives

Anti-cholinergics

Atropine Sulfate

Propanthelene Bromide

Antibiotics for infection

2. Provide dietary intake:

Diverticulosis – high roughage/fiber with no

seeds

Diverticulitis – low fiber diet

3. Assist in surgical procedure

Bowel resection: removal of diseased portion

of the bowel and creation of colostomy.

Documents

Gastrointestinal system