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GASTROINTESTINAL NURSING
Digestive Tract Disorders 2013
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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
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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
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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
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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
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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???
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Diagnostic Tests & Procedures
Gastrointestinal System
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Stool Specimens O&P OB Fecal Fat C & S
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RADIOGRAPHIC TESTS Most common tests: 1) Barium swallow or UGI
2) Small Bowel series 3) Barium enema Others: CTS,US abd. X-rays
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ENDOSCOPIC TESTS (for upper GI system)
Esophagoscopy Gastroscopy Gastroduodenoscopy EGD ERCP
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ENDOSCOPIC TESTS ( for lower GI system)
Colonoscopy Proctoscopy Sigmoidoscopy
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Laboratory Tests Gastric Analysis CBC PT (prothrombin time) INR
PTT (partial thromboplastin time)
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Bilirubin Blood proteins Alkaline Phosphatase LDH GGT
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AST ALT Cholesterol & Triglycerides Amylase CEA
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Abnormal Assessment Findings
Distention Firmness Tenderness Altered bowel sounds
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Therapeutic Measures & Related Nursing Interventions
With GI Patients
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Gavage or Enteral Nutrition (Tube Feedings)
Provide nutritional support through a tube Short or long term In conditions that prohibit oral nourishment
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Gastric Decompression
Types of tubes ( pg. 780 ) What is the purpose of gastric decompression? ??Nursing Interventions??
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Types of Tubes Nasogastric - (NG) Gastrostomy – (G-tube) Jejunal – (J-tube) Percutaneous – (PEG)
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Figure 38-6
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Total Parenteral Nutrition – (TPN)
Nutritionally complete Used when GI system not functioning Short or long term
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Figure 38-9
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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.
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Pre-Op Nursing Interventions
. For GI surgery patients
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GI tract cleansing Assess vital signs Liquids for 24 hrs. or NPO IV Antibiotics NGT insertion
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Post-Op Nursing Interventions
For GI surgery patients
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Relieve pain Detect complications Prevent gastric distention Replace lost fluids Maintain urine elimination
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Digestive Disorders
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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
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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
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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
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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
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Obesity 20% over ideal body wt. Morbid obesity= 2X normal body wt.
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Complications CV disease Diabetes Respiratory difficulties
Musculoskeletal problems Emotional and social isolation
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Causes Caloric intake > expenditure Heredity
Emotional stress/psychosocial factors Slowed metabolism
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Medical Management Weight reduction diet Exercise Medication Counseling
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Surgical Treatment RNYGBP VBG LBP Liposuction Dumping Syndrome
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Show what you know… List 3 Nursing Diagnosis & related Nursing Interventions for the: OBESE PATIENT
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Disorders of the Mouth
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Dental Caries Destructive process of tooth decay Causes: Bacteria
Poor oral hygiene .
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Prevention Frequent brushing and flossing Dentist visit 2X/yr Good nutrition Fluoride
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Treatment Removal of diseases portion of tooth and filling May need dentures If untreated, may lead to periodontal disease
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Stomatitis Inflammation of the oral mucosa Causes are???
Treatment is ??? What is Aphthous Stomatitis?
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Herpes Simplex HSV Type 1 Vesicles around the mouth & lips
Tx is comfort not curative Zovarax ointment (antiviral)
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Candidiasis Fungal infection (Thrush) Candida Albicans
White patches in mouth Immunosuppression Abx therapy
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DISORDERS OF THE TEETH & GUMS
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Periodontal Disease Gingivitis(inflammation of gums and supporting tissues) Gums are red, swollen, painful and bleed easily Cause poor oral hygiene & nutrition
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SHOW WHAT YOU KNOW… Assessment…? Nursing Diagnosis….? Interventions….?
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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
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Risk Factors Tobacco use Alcohol use Poor nutrition Chronic irritation
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Treatment Chemo Radiation Surgery
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Post Op Care Radical Neck
Impaired oral mucous membrane Ineffective breathing pattern Acute pain NGT, PEG, or TPN Disturbed Body Image
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Disorders of Esophagus
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Esophageal Cancer Not common, poor prognosis
Middle or lower portion of esophagus No known cause
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Predisposing Factors Cigarette smoking Excessive alcohol intake Poor oral hygiene Eating spicy foods
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Signs and Symptoms Progressive dysphagia Weight loss may be dramatic
TX Chemo or surgery Esophagectomy, Esophagogastrostomy, or Esophagogastrectomy
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Nursing Care of the patient with Esophageal CA
Assessment….? Nursing Diagnosis….? Interventions….? Nutrition Anxiety Risk for infection, injury
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Esophageal Diverticulum
Esophageal out-pouching Zenker’s Diverticulum “Bad breath” due to accumulation of food in diverticulum
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Treatment Bland diet Antacids Anti-emetics Surgery
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Pre-Op Nursing Measures
Semi-fowlers Small meals Loose clothing
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Disorders Affecting Digestion
And Absorption
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Hiatal Hernia Protrusion of the lower esophagus and stomach upward through the diaphragm Two types: Sliding and Rolling
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Causes Weakness of muscles of diaphragm Exact cause is unknown
Excessive intra-abdominal pressure
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Contributing Factors Obesity Pregnancy Abdominal tumors, ascites or repeated heavy lifting
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Signs and Symptoms Feeling of fullness Eructation Heartburn Dysphagia
Regurgitation
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Medical Treatment Avoid increased intra-abdominal pressure
HOB ^ 6-12 inchesprevents nighttime reflux Drug Therapy Diet
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Surgical Treatment Nissen Fundoplication Angelchik Prosthesis
Figure & 38-15
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Nissen Fundoplication
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THINK !! Describe your Post-Op Nrsg Interventions for this patient? ia
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GERD Gastroesophageal Reflux Disease
Backward flow of stomach contents into the espohagus Sometimes occurs with a sliding hiatal hernia
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WHAT IS “NERD” ???
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Signs & Symptoms Burning sensation that moves up and down, commonly after meals Intermittent dysphagia belching
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Diagnosis Based on symptoms Sx relief w/ PPI; return when DC’d
Endoscopy Gastric analysis
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Med Treatment & Nrsg Care
Same as for hiatal hernia Drug therapy may include: Zantac, Reglan, Prilosec & antacids Fundoplication if required
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Patient Teaching Avoid ASA and NSAIDS Chew food well
Avoid eating 2 hrs. before bedtime
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Gastritis Inflammation of the stomach mucosa/lining
Several types; same pathophysiology H-pylori prime culprit; NSAIDS, stress, ETOH
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Signs & Symptoms N/V Abdominal pain Anorexia Feeling of fullness
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Treatment Meds Replacement of fluids after N,V & diarrhea subsides
Elimination of the cause Tx & nrsg. Interventions same as for Ulcer Disease
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THINK….. List 3 Nursing Diagnosis and related interventions when caring for the patient with gastritis What teaching would you do with this patient???
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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
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Causes Bacterium H. pylori ASA, NSAIDS Physical trauma (shock,burns)
Foods or conditions that cause excessive gastric acid secretions
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Comparison of Peptic Ulcers
GASTRIC DUODENAL Incidence Ulcer depth S/S Complications Incidence Ulcer depth S/S Complications
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Very Important Patient Teaching
1) Limit milk products 2) No baking soda
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Complications of Peptic Ulcers
Hemorrhage Perforation Peritonitis Obstruction
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Medical Treatment Drug therapy Diet therapy NGT hemorrhage
Saline Lavage Surgical treatment options Table 38-6 Fig
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Complications after Gastrectomy
Dumping syndrome pg. 813 Sx occur within 20 min of eating Bloating, flatulence, cramps & diarrhea Diaphoresis, anxious, shaky Malabsorption--> Malnutrition
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THINK… What teaching would you provide to the patient experiencing Dumping Syndrome??
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Stomach Cancer “Silent neoplasm” Poor prognosis No early s/s
Late s/s: vomiting, ascites, abd. Mass, enlarged liver
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Risk Factors H-pylori infection Pernicious anemia Chronic gastritis
Family history
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Treatment Chemo Radiation Surgery
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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???/
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AbSORPTION & ELIMINATION
Disorders Affecting AbSORPTION & ELIMINATION
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Malabsorption Intestinal absorption of nutrients is reduced
Two examples are: Celiac sprue/disease Lactase deficiency
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Signs & Symptoms Steatorrhea Malnutrition & weight loss
Abdominal pain, cramping Bloating diarrhea
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Treatment Sprue diet and drug therapy, avoid foods w/ gluten(wheat, barley, oats) Lactase avoid milk products & take lactase enzyme ( Lactaid)
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Critical Thinking Question
A 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?
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THAT’S IT…!! YOUR DONE WITH GI UNIT 1 ON TO UNIT 2…..
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