Chapter 5 Care of the Patient with a Gastrointestinal Disorder

Chapter 5 Care of the Patient with a Gastrointestinal Disorder
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Overview of Anatomy and Physiology
Digestive system (Alimentary canal) Organs and their functions Mouth: Beginning of digestion Teeth: Bite, crush, and grind food Salivary glands: Secrete saliva Esophagus: Moves food from mouth to stomach Stomach: Churn and mix contents with gastric juices Small intestine: Most digestion occurs here Large intestine: Forms and expels feces Rectum: Expels feces Peristalsis: coordinated, rhythmic, serial contraction of smooth muscle that forces food through digestive tract, bile through bile duct and urine through ureter It is a well understood fact that the digestive system functions to process the foods and nutrients taken into the body. Along its journey, the food becomes involved with a group of supportive organs known as accessory organs. What function do accessory organs serve for the digestive system?

Location of digestive organs.
Figure 5-1 The digestive process begins in the mouth. From the time the food enters the mouth, the chemical digestive process begins. Review the chemicals and enzymes secreted in the process of digestion. Where do these substances enter the alimentary canal? What is their source? The fundamental purpose of dietary intake is to nourish the body. At what point do the nutritional sources begin to be absorbed by the body? What processes facilitate this to occur? (From Thibodeau, G.A., Patton, K.T. [2007]. Anatomy and physiology. [6th ed.]. St. Louis: Mosby.) Location of digestive organs.

Overview of Anatomy and Physiology
Accessory organs of digestion Organs and their functions Liver: Produces bile; stores it in the gallbladder Pancreas: Produces pancreatic juice Regulation of food intake Hypothalamus One center stimulates eating and another signals to stop eating Discuss the sequence of the digestive process. Be sure to note the function of each of the organs in the steps.

Laboratory and Diagnostic Examinations
Upper GI series: NPO & expulsion of barium Gastric analysis: determine presence of acid Esophagogastroduodenoscopy (EGD): NPO, IV Capsule endoscopy Barium swallow: more thorough esophageal exam; barium or gastrografin Bernstein test: acid-perfusion test (reproduce acid reflux) Stool for occult blood: Guaiacoccult, Hemoccult, Hematest Sigmoidoscopy: lower GI tract Barium enema: radiographic images of colon Colonoscopy: clear liquid diet; cleansing of colon Stool culture and sensitivity; stool for ova and parasites Flat plate of the abdomen: detect air-fluid levels within intestine The majority of diagnostic exams associated with the digestive system are used to visualize the areas of concern. When a patient is scheduled for a diagnostic exam, what are the responsibilities of the nurse? What responsibilities are associated with the physician? How do these scopes of practice/responsibility differ? For each of the diagnostic tests listed, what preparation is required? Review the documentation that is necessary concerning the preparation. What are the nursing responsibilities after each of the procedures?

Disorders of the Mouth Dental plaque and caries
Etiology/pathophysiology Erosive process that results from the action of bacteria on carbohydrates in the mouth, which produces acids that dissolve tooth enamel Medical management/nursing interventions Remove affected area and replace with dental material Dental decay is a phenomenon having a profound impact on the health of Americans. It is estimated 95% of Americans will experience dental decay during their lives. What factors are associated with dental decay? Identify steps to prevent dental decay. What is the impact of dental decay on the patient’s health status?

Disorders of the Mouth Candidiasis Etiology/pathophysiology
Infection caused by a species of Candida, usually Candida albicans Fungus normally present in the mouth, intestine, and vagina, and on the skin Also referred to as thrush and moniliasis Clinical manifestations/assessment Small white patches on the mucous membrane of the mouth Thick white discharge from the vagina Candidiasis is a fungal infection. List factors that can contribute to the development of a candidiasis infection.

Disorders of the Mouth Candidiasis (continued)
Medical management/nursing interventions Pharmacological management Nystatin Ketoconazole oral tablets Half-strength hydrogen peroxide/saline mouthwash Meticulous handwashing Comfort measures When caring for a patient having a candidiasis infection, what are the nursing responsibilities? Please include care, assessment, and health teaching.

Disorders of the Mouth Carcinoma of the oral cavity
Etiology/pathophysiology Malignant lesions on the lips, oral cavity, tongue, or pharynx Usually squamous cell epitheliomas Clinical manifestations/assessment Leukoplakia Roughened area on the tongue Difficulty chewing, swallowing, or speaking Edema, numbness, or loss of feeling in the mouth Earache, face ache, and toothache In the United States, 2% to 4% of cancers are oral in nature. Unfortunately, the number of young people suffering from oral cancers continues to grow. What factors can be attributed to this occurrence? The mortality rate of oral cancers involves the high degree of metastasis seen in them. Discuss the causes associated with the mortality rates of oral cancer. Differentiate between early and late signs and symptoms associated with oral cancer.

Disorders of the Mouth Carcinoma of the oral cavity (continued)
Diagnostic tests Indirect laryngoscopy Excisional biopsy Medical management/nursing interventions Stage I: Surgery or radiation Stage II & III: Both surgery and radiation Stage IV: Palliative Surgical complications possible: nerve damage, airway obstruction, hemorrhage, aspiration, edema, dysphagia PEG tube insertion may be required Prognosis: dependant on staging Expound on the manner in which the diagnostic examinations differ with the type of suspected oral malignancy being evaluated. Identify factors that determine what type of medical management options will be utilized.

Disorders of the Esophagus
Gastroesophageal reflux disease Etiology/pathophysiology Backward flow of stomach acid into the esophagus If left untreated, can turn to Barrett’s esophagus Clinical manifestations/assessment Heartburn (pyrosis) 20 min to 2 hours after eating Regurgitation Dysphagia or odynophagia Eructation Gastroesophageal reflux disease is commonly referred to as GERD. GERD is the reflux of stomach acid into the esophagus. What factors are associated with the development of this manifestation? Discuss attributes that impact the severity of the disorder.

Gastroesophageal reflux disease (continued) Diagnostic tests Esophageal motility and Bernstein tests Barium swallow Endoscopy Medical management/nursing interventions Pharmacological management Antacids or acid-blocking medications Dietary recommendations; small, frequent meals, reduce caffeine/alcohol, avoid eating 2-3 hours before bedtime Lifestyle recommendations; smoking cessation, avoid heavy lifting, straining, sleep with head of bed elevated Comfort measures Surgery Prognosis: poor if left untreated Discuss the rationale for the prescribed nursing actions. Are there any dietary modifications that can be used to alleviate symptoms? Outline the mode of action for the medications commonly used to manage GERD.

Carcinoma of the esophagus Etiology/pathophysiology Malignant epithelial neoplasm that has invaded the esophagus 90% are squamous cell carcinoma associated with alcohol intake and tobacco use 6% are adenocarcinomas associated with reflux esophagitis Typically discovered at late stage making prognosis poor and palliative treatment common Clinical manifestations/assessment Progressive dysphagia over a 6-month period Sensation of food sticking in throat Review risk factors for the development of carcinoma of the esophagus.

Carcinoma of the esophagus (continued) Medical management/nursing interventions Radiation: May be curative or palliative Surgery: May be palliative, increase longevity, or curative Types of surgical procedures Esophagogastrectomy Esophagogastrostomy Esophagoenterostomy Gastrostomy The patient having oral or esophageal cancer has both psychological and physiological needs. What are the nursing responsibilities in the plan of care for these patients?

Achalasia Etiology/pathophysiology Cardiac sphincter of the stomach cannot relax Possible causes: Nerve degeneration, esophageal dilation, and hypertrophy Clinical manifestations/assessment Dysphagia Regurgitation of food Substernal chest pain Loss of weight; weakness Poor skin turgor What are the results of achalasia? What is the underlying cause of the disorder? Review at-risk populations. Explain the reason for the signs and symptoms that occur with the disorder. Separate and identify the early and late clinical manifestations.

Achalasia (continued) Diagnostic tests Radiologic studies; esophagoscopy Medical management/nursing interventions Pharmacological management Anticholinergics, nitrates, and calcium channel blockers Dilation of cardiac sphincter Surgery Cardiomyectomy The chief diagnostic studies used for achalasia involve radiologic studies or esophagoscopy. What findings are indicative of this condition?

Disorders of the Stomach
Acute gastritis Etiology/pathophysiology Inflammation of the lining of the stomach May be associated with alcoholism, smoking, and stressful physical problems Clinical manifestations/assessment Fever; headache Epigastric pain; nausea and vomiting Coating of the tongue Loss of appetite

Acute gastritis (continued) Diagnostic tests Stool for occult blood; WBC; electrolytes Medical management/nursing interventions Pharmacological management Antiemetics Antacids Antibiotics IV fluids NG tube and administration of blood, if bleeding NPO until signs and symptoms subside Monitor intake and output Review the common names of medications commonly used in the management of acute gastritis. Develop appropriate nursing diagnoses for the patient with acute gastritis.

Peptic Ulcers Gastric ulcers and duodenal ulcers
Ulcerations of the mucous membrane or deeper structures of the GI tract Most commonly occur in the stomach and duodenum Result of acid and pepsin imbalances H. pylori Bacterium found in 70% of patients with gastric ulcers and 95% of patients with duodenal ulcers What variables are implicated in the development of a gastric ulcer? H. pylori has been associated with gastric ulcer occurrence. What is H. pylori? How do individuals become infected with the bacterium?

Gastric ulcers (continued) Etiology/pathophysiology Gastric mucosa are damaged, acid is secreted, mucosal erosion occurs, and an ulcer develops Duodenal ulcers (continued) Excessive production or release of gastrin, increased sensitivity to gastrin, or decreased ability to buffer the acid secretions Discuss stress ulcers. How do they develop?

Gastric and duodenal ulcers (continued) Clinical manifestations/assessment Pain: Dull, burning, boring, or gnawing, epigastric Dyspepsia Hematemesis Melena Diagnostic tests Esophagogastroduodenoscopy (EGD) Breath test for H. pylori Explain the underlying cause for the signs and symptoms experienced by the patient suffering from a gastric ulcer.

Fiberoptic endoscopy of the stomach.
Figure 5-5 Discuss the use of fiberoptic endoscopy of the stomach to diagnose gastrointestinal disorders. (from Monahan, F.D., et al. [2007]. Phipps’ medical-surgical nursing: health and illness perspectives. [8th ed.]. St. Louis: Mosby.) Fiberoptic endoscopy of the stomach.

Gastric and duodenal ulcers (continued) Medical management/nursing interventions Pharmacological management Antacids Histamine H2 receptor blockers Proton pump inhibitor Mucosal healing agents Antibiotics Dietary recommendations small frequent meals; limit coffee, tobacco, alcohol, and aspirin use Develop teaching plans for the patient with a gastric or duodenal ulcer. What are the nursing responsibilities for the patient with an ulcer? What are the goals of treatment for patients experiencing gastric and duodenal ulcers?

Gastric and duodenal ulcers (continued) Medical management/nursing interventions Surgery Antrectomy Gastroduodenostomy (Billroth I) Gastrojejunostomy (Billroth II) Total gastrectomy Vagotomy Pyloroplasty May require NG tube placement Surgical intervention is needed for approximately 20% of patients having ulcers. The decision to perform surgery is determined by the patient’s unique health status. What events may necessitate a patient having surgery to treat gastric ulcers? Outline the differences between the surgical procedures that might be used in the treatment of patients diagnosed with ulcers.

Figure 5-7 Types of gastric resections with anastomoses.
A, Billroth I. B, Billroth II.

Gastric and duodenal ulcers (continued) Complications after gastric surgery Dumping syndrome Pernicious anemia Iron deficiency anemia At what point in the postoperative process are the complications of dumping syndrome, pernicious anemia, and iron deficiency most likely to occur? What impact do these complications have on the patient’s health status? How are the potential complications prevented and managed?

Cancer of the stomach Etiology/pathophysiology Most commonly adenocarcinoma Primary location is the pyloric area Risk factors: History of polyps Pernicious anemia Hypochlorhydria Gastrectomy; chronic gastritis; gastric ulcer Diet high in salt, preservatives, and carbohydrates Diet low in fresh fruits and vegetables Although the rates of gastric cancer are declining in the United States, it still remains a cause of concern. Studies have identified risk factors for the development of gastric cancer. Why do patients experiencing these circumstances have a higher risk of gastric cancer development?

Cancer of the stomach (continued) Clinical manifestations/assessment Early stages may be asymptomatic Vague epigastric discomfort or indigestion Postprandial fullness Ulcer-like pain that does not respond to therapy Anorexia; weight loss Weakness Blood in stools; hematemesis Vomiting after fluids and meals The patient suffering from gastric cancer may be asymptomatic initially. What signs and symptoms are seen early in the development of the disease? What signs and symptoms are considered late? Anemia can also accompany gastric cancer. Why does the patient experience anemia?

Cancer of the stomach (continued) Diagnostic tests GI series Endoscopic/gastroscopic examination Stool for occult blood RBC, hemoglobin, and hematocrit Medical management/nursing interventions Surgery Partial or total gastric resection Chemotherapy and/or radiation Prognosis: usually poor due to lack of clinical signs and metastasis What findings are typically found to support a diagnosis of gastric cancer? After a diagnosis of gastric cancer is found, what treatment options are available? What is the role of the nurse when caring for the patient experiencing gastric cancer?

Disorders of the Intestines
Infection Etiology/pathophysiology Invasion of the alimentary canal by pathogenic microorganisms Most commonly enters through the mouth in food or water Person-to-person contact Fecal-oral transmission Long-term antibiotic therapy can cause an overgrowth of the normal intestinal flora (C. difficile) There are numerous means for the intestinal tract to be exposed to infectious matter. With so many available avenues to become infected, how does the body resist these infections? List some of the potential pathogens that can affect the intestinal tract.

Infection (continued) Clinical manifestations/assessment Diarrhea Rectal urgency Tenesmus Nausea and vomiting Abdominal cramping Fever The typical patient experiencing an intestinal infection will present with complaints of nausea, vomiting, and diarrhea. These symptoms are common and might accompany other disorders. To aid the physician in making a diagnosis, what additional data should the nurse attempt to collect from the patient?

Infection (continued) Diagnostic tests Stool culture Medical management/nursing interventions Antibiotics Fluid and electrolyte replacement Kaopectate Pepto-Bismol When collecting a stool specimen, what education should be given to the patient? How should the stool be handled after collection? What are the nursing responsibilities/implications in the treatment plan?

Irritable bowel syndrome Etiology/pathophysiology Episodes of alteration in bowel function Spastic and uncoordinated muscle contractions of the colon Clinical manifestations/assessment Abdominal pain Frequent bowel movements Sense of incomplete evacuation Flatulence, constipation, and/or diarrhea Irritable bowel syndrome (IBS) is a common disorder possibly affecting 20% of the population. What causes IBS?

Irritable bowel syndrome (continued) Diagnostic tests History and physical examination Medical management/nursing interventions Pharmacological management Anticholinergics Milk of magnesia Mineral oil Opioids Antianxiety agents Dietary recommendations Bulking agents; increase fiber Prognosis: good with good diet and stress managment The diagnosis of IBS is often made by taking a history and performing a physical examination. What elements in the patient’s health history should be reviewed? Treatment for IBS includes diet and bulking agents. Review the dietary recommendations for the patient diagnosed with IBS. What effect do bulking agents have on the bowel? Review the desired mode of action and desired outcomes for the classifications of medications prescribed to treat IBS. In addition to the traditional medication therapy, alternative therapies are being used to treat the disorder. Discuss their use.

Ulcerative colitis Etiology/pathophysiology Ulceration of the mucosa and submucosa of the colon Tiny abscesses form that produce purulent drainage, slough the mucosa, and ulcerations occur Twice the incidence of Crohn’s disease Clinical manifestations/assessment Diarrhea—pus and blood; 15 to 20 stools per day Abdominal cramping Involuntary leakage of stool Ulcerative colitis is a chronic inflammatory bowel disease. What portion of the bowel is involved in ulcerative colitis? Discuss the progression of the disease.

Ulcerative colitis (continued) Diagnostic tests Barium studies, colonoscopy, stool for occult blood Medical management/nursing interventions Pharmacological management Azulfidine, Dipentum, Rowasa, corticosteroids, Imodium Dietary recommendations: No milk products or spicy foods; high-protein, high-calorie; total parenteral nutrition Stress control Assist patient to find coping mechanisms Review the factors that are utilized to determine the course of treatment. Medications prescribed for the management of ulcerative colitis include sulfasalazine, non-sulfa drugs, corticosteroids, and antidiarrheal agents. How do these medications work?

Ulcerative colitis (continued) Medical management/nursing interventions Surgical interventions Colon resection Ileostomy Ileoanal anastomosis Proctocolectomy Kock pouch Maintain periostomal skin integrity; provide emotional support Surgical interventions might be used to manage ulcerative colitis if the condition does not respond to traditional therapies. Review the surgical interventions that could be used to treat ulcerative colitis. What are the nursing assessment responsibilities during the postoperative phase?

Kock pouch (Kock continent ileostomy).
Figure 5-9 Kock pouch (Kock continent ileostomy).

Ileostomy with absence of resected bowel.
Figure 5-10 Ileostomy with absence of resected bowel.

Crohn’s disease Etiology/pathophysiology Inflammation, fibrosis, scarring, and thickening of any/all layers bowel wall Can occur anywhere in the intestines Clinical manifestations/assessment Weakness; loss of appetite Diarrhea: 3 to 4 daily; contain mucus and pus Right lower abdominal pain Steatorrhea Anal fissures and/or fistulas Crohn’s disease is an inflammatory bowel disease with an increasing incidence in the United States. What factors might be associated with this increase? Identify the population affected most by Crohn’s disease. Review the progression of the disease. The disease is associated with significant changes in bowel habits. What type of bowel function is characteristic of Crohn’s disease?

Crohn’s disease (continued) Medical management/nursing interventions Pharmacological management Corticosteroids Azulfidine Antibiotics Antidiarrheals; antispasmodics Enteric-coated fish oil capsules B12 replacement Once a diagnosis of Crohn’s disease is made, a plan of treatment is devised. What factors play a role in the determination of the plan of care? Medications are used to treat Crohn’s disease. What mode of action does each of medication classification have?

Crohn’s disease (continued) Medical management/nursing interventions Dietary recommendations High-protein Elemental Hyperalimentation Avoid Lactose-containing foods, brassica vegetables, caffeine, beer, monosodium glutamate, highly seasoned foods, carbonated beverages, fatty foods Surgery Segmental resection of diseased bowel Prognosis: chronic condition with high rates of recurrence Dietary management is a central part of the patient’s treatment plan. Review the dietary modifications that might be recommended to the patient with Crohn’s disease. What role does each of the elements of the dietary plan have in the management of this condition?

Appendicitis Etiology/pathophysiology Inflammation of the vermiform appendix Lumen of the appendix becomes obstructed, the E. coli multiplies, and an infection develops Clinical manifestations/assessment Rebound tenderness over the right lower quadrant of the abdomen (McBurney’s point) Vomiting Low-grade fever Elevated WBC Appendicitis occurs when the vermiform appendix becomes inflamed. What is the vermiform appendix? What is its physiological purpose? Where is it located? How should the assessment be performed for the patient who is suspected of having appendicitis?

Appendicitis (continued) Diagnostic tests WBC Roentgenogram Ultrasound Laparoscopy Medical management/nursing interventions Appendectomy Once a patient presents with the clinical signs and symptoms indicative of appendicitis, diagnostic tests are performed to establish additional supportive data. What findings on the white blood cell count will support a diagnosis of appendicitis? When a diagnosis of appendicitis is confirmed, surgery will be performed. What measures/interventions are contraindicated? Why?

Diverticular disease Etiology/pathophysiology Diverticulosis Pouch-like herniations through the muscular layer of the colon Diverticulitis Inflammation of one or more diverticula Review the clinical process that accompanies diverticulosis/diverticulitis.

Figure 5-11 Diverticulosis.

Diverticular disease (continued) Clinical manifestations/assessment Diverticulosis May have few, if any, symptoms Constipation, diarrhea, and/or flatulence Pain in the left lower quadrant Diverticulitis Mild to severe pain in the left lower quadrant Elevated WBC; low-grade fever Abdominal distention Vomiting Blood in stool Differing symptoms are associated with diverticulosis and diverticulitis. Why do these clinical presentations differ?

Diverticular disease (continued) Medical management/nursing interventions Diverticulosis with muscular atrophy Low-residue diet; stool softeners Bed rest Diverticulosis with increased intracolonic pressure and muscle thickening High-fiber diet Sulfa drugs Antibiotics; analgesics The treatment of diverticulosis and diverticulitis can include medication, dietary modification, and surgery. Review factors that could be used to determine the best course of treatment.

Diverticular disease (continued) Medical management/nursing interventions (continued) Surgery Hartmann’s pouch Double-barrel transverse colostomy Transverse loop colostomy What nursing diagnoses can be utilized in the plan of care for the patient diagnosed with diverticulosis or diverticulitis?

Peritonitis Etiology/pathophysiology Inflammation of the abdominal peritoneum Bacterial contamination of the peritoneal cavity from fecal matter or chemical irritation Clinical manifestations/assessment Severe abdominal pain; nausea and vomiting Abdomen is tympanic; absence of bowel sounds Chills; weakness Weak rapid pulse; fever; hypotension Peritonitis is a serious infection in the abdominal peritoneum. What factors might be associated with the development of this condition?

Peritonitis (continued) Diagnostic tests Flat plate of the abdomen CBC Medical management/nursing interventions Pharmacological management Parenteral antibiotics Analgesics IV fluids Position patient in semi-Fowler’s position Surgery Repair cause of fecal contamination Removal of chemical irritant NG tube to prevent GI distention The treatment of peritonitis is aggressive. What patient teaching should be provided concerning the disease, its management, and its prognosis?

External hernias Etiology/pathophysiology Congenital or acquired weakness of the abdominal wall or postoperative defect Abdominal Femoral or inguinal Umbilical The protrusion of a viscus through an abdominal opening, or weakened area in which it is usually contained, results in a hernia. Identify populations at risk for the development of hernias. Which of their attributes place them at increased risk?

External hernias (continued) Clinical manifestations/assessment Protruding mass or bulge around the umbilicus, in the inguinal area, or near an incision Incarceration Strangulation Diagnostic tests Radiographs Palpation Define reducible, incarcerated, and strangulated hernias. What medical concerns accompany incarcerated and strangulated hernias?

External hernias (continued) Medical management/nursing interventions If no discomfort, hernia is left unrepaired, unless it becomes strangulated or obstruction occurs Truss Surgery Synthetic mesh is applied to weakened area of the abdominal wall Discuss assessment of the patient presenting with a hernia. Review the signs and symptoms signaling a complication with the hernia.

Hiatal hernia Etiology/pathophysiology Protrusion of the stomach and other abdominal viscera through an opening in the membrane or tissue of the diaphragm Contributing factors: obesity, trauma, aging Clinical manifestations/assessment Most people display few, if any, symptoms Gastroesophageal reflux What complications may result with a hiatal hernia?

Hiatal hernia. A, Sliding hernia. B, Rolling hernia.
Figure 5-15 A hiatal hernia could be sliding or rolling. How do they differ? Hiatal hernia. A, Sliding hernia. B, Rolling hernia.

Hiatal hernia (continued) Medical management/nursing interventions Head of bed should be slightly elevated when lying down Surgery Posterior gastropexy Transabdominal fundoplication (Nissen) What nursing diagnoses would be appropriate for inclusion in a care plan for the patient diagnosed with a hiatal hernia? When caring for the patient with a hiatal hernia, what should be included in the teaching plan for the patient?

Intestinal obstruction Etiology/pathophysiology Intestinal contents cannot pass through the GI tract Partial or complete Mechanical Non-mechanical Clinical manifestations/assessment Vomiting; dehydration Abdominal tenderness and distention Constipation Intestinal obstruction is a serious medical complication. It could be mechanical or non-mechanical. What are possible causes of mechanical obstructions? Non-mechanical obstructions? Why is the development of an intestinal obstruction serious? What are the clinical implications associated with an intestinal obstruction? The clinical manifestations of an intestinal obstruction vary with location and onset. What are early signs and symptoms associated with an intestinal obstruction?

Intestinal obstructions. A, Adhesions. B, Volvulus.
Figure 5-17 Intestinal obstructions. A, Adhesions. B, Volvulus.

Intestinal obstruction (continued) Diagnostic tests Radiographic examinations BUN, sodium, potassium, hemoglobin, and hematocrit Medical management/nursing interventions Evacuation of intestine NG tube to decompress the bowel Nasointestinal tube with mercury weight Surgery Required for mechanical obstructions Radiographic studies provide a visualization of the abdomen and bowel. What findings are present with x-ray studies that support a diagnosis of intestinal obstruction? How are electrolyte levels impacted when an intestinal obstruction is located? What nursing assessments are required when caring for the patient with an intestinal obstruction?

Colorectal cancer Etiology/pathophysiology Malignant neoplasm that invades the epithelium and surrounding tissue of the colon and rectum Second most prevalent internal cancer in the United States Clinical manifestations/assessment Change in bowel habits; rectal bleeding Abdominal pain, distention, and/or ascites Nausea Cachexia Colon cancer equally affects men and women. An estimated 70% of colon cancers are found in the sigmoid, rectal, cecum, and ascending colon. Studies have pinpointed risk factors associated with the development of colon cancer. Review the risk factors. Review the signs and symptoms of colon cancer. Differentiate between early and late manifestations.

Cancer of the colon (continued) Diagnostic tests Proctosigmoidoscopy with biopsy Colonoscopy Stool for occult blood Medical management/nursing interventions Radiation Chemotherapy Early diagnosis of colon cancer is key in preventing death. What preventative tests are available to detect colon cancer? Review the medical recommendations for preventive screening. In the event colon cancer is suspected, what diagnostic test findings are indicative of the disease?

Cancer of the colon (continued) Medical management/nursing interventions (continued) Surgery Obstruction One-stage or two-stage resection Two-stage resection Colorectal cancer Right or left hemicolectomy Anterior rectosigmoid resection When the medical management of colon cancer includes surgical intervention, a number of options are available. Compare and contrast the surgical interventions used in the treatment plan. What are the nursing responsibilities during the postoperative period? What is the prognosis for colon cancer? What determines the patient’s prognosis?

Hemorrhoids Etiology/pathophysiology Varicosities (dilated veins) External or internal Contributing factors Straining with defecation, diarrhea, pregnancy, CHF, portal hypertension, prolonged sitting and standing Clinical manifestations/assessment Varicosities in rectal area Bright red bleeding with defecation Pruritus Severe pain when thrombosed

Hemorrhoids (continued) Medical management/nursing interventions Pharmacological management Bulk stool softeners Hydrocortisone cream Topical analgesics Sitz baths Ligation Sclerotherapy; cryotherapy Infrared photocoagulation Laser excision Hemorrhoidectomy In most cases, hemorrhoids respond to conservative management. Discuss the desired outcomes of each of the treatment options.

Anal fissure Linear ulceration or laceration of the skin of the anus Usually caused by trauma Lesions usually heal spontaneously May be excised surgically Anal fistula Abnormal opening on the surface near the anus Usually from a local abscess Common in Crohn’s disease Treated by a fistulectomy or fistulotomy What are examples of patients who have fissures?

Fecal incontinence Potential causes Medical management/nursing interventions Biofeedback training Bowel training Patient education Dietary recommendations Discuss the steps that should be included in a bowel training plan.

Nursing Process Nursing diagnoses Activity intolerance Anxiety
Body image, disturbed Constipation Coping, ineffective Diarrhea Fear Fluid volume, deficient, risk for Home management, impaired Management of therapeutic regimen, ineffective Nutrition, imbalanced: less than body requirements Pain, chronic/acute Skin integrity, risk for impaired Sleep pattern, disturbed Social isolation Tissue perfusion, ineffective Disorders of the digestive system are often invasive and far-reaching. There is immeasurable impact on the patients affected. Review the provided nursing diagnoses. Which of the digestive disorders do they most pertain to?

Gastrointestinal Medications
Chapter 19 Gastrointestinal Medications Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc. 69

Overview Three major types of GI medications: restore and maintain the lining of the GI tract; decrease acidity and motility; exert laxative action on the colon Miscellaneous medications: antiflatulents, digestive enzymes, emetics, and medications to treat gallstones and alcoholism What is a common OTC drug used in the treatment of GI disorders? Why would an emetic be ordered? If a patient has undergone a gastric bypass procedure, which GI medication may be prescribed? Laxatives work in several ways. They promote bowel emptying by increasing intestinal bulk, lubricating intestinal walls, softening the fecal mass, increasing peristalsis through local tissue irritation, or by direct action on the intestine. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Digestive System Functions Structures Protective factors
Digestion variables What are the three functions of the digestive system? How does the amount of blood flow to the digestive tract affect the body’s ability to absorb medications? What is the other name for the digestive tract? What role does age play in the normal digestive process? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Antacids, H2-Receptor Antagonists, Proton Pump Inhibitors
Stomach lining and acid production External factors that contribute to ulcer formation Protective medications Table 19-1 What clinical factors may play a role in increased acid production in the stomach? Why would a GI-protective drug be prescribed in combination with NSAIDs? Drug treatment includes the use of antacids, H2-receptor antagonists, and proton pump inhibitors Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Antacids, H2-Receptor Antagonists, Proton Pump Inhibitors (cont.)
Action and Uses Antacids neutralize hydrochloric acid and decrease gastric pH; inhibit pepsin Histamine H2-receptor antagonists displace histamine from the receptor site and prevent stimulation of the secretory cells (neutralize acid and promote healing of ulcers) Proton pump inhibitors irreversibly stop the acid secretory pump embedded in the parietal cells Of the three drugs, which classification is considered first-line therapy in the treatment of peptic ulcer disease over 6 to 8 weeks? What conditions would antacids be used to treat? How are ulcers caused by Helicobacter pylori treated? When would proton pump inhibitors be used for long-term therapy? How do misoprostol and sucralfate differ in their action? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Adverse Reactions Antacids: weakness, anorexia, diarrhea, frequent burping, bowel obstruction, constipation, hypermagnesemia H2-receptor antagonists: dizziness, headache, somnolence, mild/brief diarrhea, hematologic changes, muscle pain Proton pump inhibitors: headache, diarrhea, abdominal pain, and nausea; rarely rash, vomiting, and dizziness If the patient overuses antacids that contain magnesium, what symptoms might appear? Which antibiotic should not be taken with antacids? Which drugs, when combined with proton pump inhibitors, may produce serious overdose for the patient? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Drug Interactions Antacids prevent absorption of many drugs Dicumarol absorbed 50% faster when taken with antacids What are some other examples of drug interactions? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Nursing Implications and Patient Teaching Assessment: interaction possibilities Diagnosis: smoking/alcohol intake, stress Planning: increase fluid intake Implementation: forms and routes of administration vary Evaluation: continued symptoms of GI distress Patient and Family Teaching: administration times and drug specificity, adverse reactions, drug storage and efficacy, medical follow-up, drug interactions What administration considerations will the nurse note if the patient is receiving an antacid and an enteric-coated drug scheduled for the same time each day? If the patient is receiving an aluminum-containing antacid, the diet should contain adequate amounts of phosphorus. What foods are naturally high in phosphorus? If the patient is unable to swallow a proton pump inhibitor whole, what might be considered? When is the best time to administer an oral proton pump inhibitor? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Anticholinergics and Antispasmodics
Motility Symptoms Classes of medications: anticholinergics, antispasmodics, antidiarrheals Table 19-2 What contributes to the GI discomfort patients often feel? The anticholinergic-antispasmodic agents act with antacids in prolonging or continuing the therapeutic benefits of both drug categories. Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Anticholinergics and Antispasmodics (cont.)
Action and Uses Anticholinergic-antispasmodic preparations reduce GI tract spasm and intestinal motility, acid production, and gastric motility, thus reducing pain Use: peptic ulcer, pylorospasm, biliary colic, hypermotility, irritable colon, and acute pancreatitis Antidiarrheals reduce the fluid content of the stool and decrease peristalsis and motility of the intestinal tract; increase smooth-muscle tone and diminish secretions Use: treatment of nonspecific diarrhea or diarrhea caused by antibiotics Why would a GI motility agent be prescribed for an elderly patient with gastroesophageal reflux disease? When would it be inadvisable to use an antidiarrheal agent for a patient who has diarrhea? What is the action of bismuth salts on the intestines? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Adverse Reactions Anticholinergics: due to high dosages Antidiarrheals If an anticholinergic contains phenobarbital, what adverse reactions should the patient be monitored for? What is a common adverse reaction associated with long-term use of antidiarrheals? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Drug Interactions New GI stimulants, when combined with other drugs that inhibit cytochrome P450 4A4 systems, should be monitored for cardiac dysrhythmias Nursing Implications and Patient Teaching Assessment, diagnosis, planning, implementation, and evaluation If anticholinergics containing phenobarbital are combined with anticoagulants without a dosage adjustment, what type of complications could the patient be at risk for? What important questions should the LPN/LVN ask when completing a nursing assessment for GI disorders? The nurse should review the patient’s hydration and nutrition status, especially assessing for dehydration in elderly clients. What dietary considerations should the nurse teach the patient who has diarrhea? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Laxatives Aid in the elimination of stool from the rectum
Bulk-forming agents Fecal softeners Hyperosmolar or saline solutions Lubricants Stimulant or irritant laxatives Tables 19-3 and 19-4 How does the use of laxatives relate to a patient’s age? When is regular use of laxatives indicated? What problems may arise with regular laxative use? Can you identify a procedure in which laxatives may be indicated as patient preparation? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Laxatives (cont.) Action and Uses
Bulk-forming laxatives absorb water and expand, increasing the bulk and moisture content of the stool; peristalsis increases, and absorbed water softens the stool Fecal softeners lower the surface tension, which allows the fecal mass to be softened by intestinal fluids Hyperosmolar laxatives produce an osmotic effect by drawing water into the bowel, thereby promoting peristalsis and bowel movement Fecal softeners may inhibit the reabsortion of what two products by the intestine? What conditions other than constipation are bulk-forming laxatives used to treat? Why would a stool softener be indicated for the patient after rectal or cardiac surgery? Saline laxatives may be used as a bowel prep before diagnostic and surgical procedures. A patient on prolonged bedrest may be prescribed which type of laxative? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Laxatives (cont.) Action and Uses (cont.)
Lubricant laxatives create a barrier between feces and the colon, preventing colon reabsorption and causing softening of the stool Stimulant or irritant laxatives work according to the agent Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Laxatives (cont.) Adverse Reactions
Nausea and vomiting, obstruction, hypersensitivity Cramping, diarrhea Electrolyte disturbances Why is it important to provide sufficient liquids to patients receiving laxatives? If a patient has a history of chronic renal failure and is receiving a hyperosmolar laxative, what is he or she at risk of developing? Which two electrolyte values may be abnormal with excessive laxative use? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Laxatives (cont.) Drug Interactions
Reduced effectiveness of antibiotics, anticoagulants, digitalis, and salicylates when combined with laxatives Nursing Implications and Patient Teaching Assessment (CHF) Why is the use of mineral oil combined with a laxative contraindicated? If the patient chronically misuses laxatives, what clinical condition may result? What medical conditions contraindicate the use of laxatives? Why? What nutritional education for preventing constipation should the nurse provide to the patient? In addition to education about fecal softeners, what nonpharmacologic education should the patient receive? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Miscellaneous Gastrointestinal Drugs
Antiflatulents Pancreatic digestive enzymes Emetics Disulfiram Table 19-5 How does simethicone work as an antiflatulent? When would the use of an emetic be contraindicated? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Antiflatulents Break up and prevent mucus-surrounded pockets of gas from forming in the intestine; reduce gastric pain Intended for short-term use When is the use of activated charcoal indicated? What physical assessments would the nurse observe in the patient who has excessive gas? Antiflatulents are often used in combination with what other GI drug? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Gallstone-Solubilizing Agents
Act on the liver to suppress cholesterol and cholic acid synthesis; biliary cholesterol desaturation is enhanced, and breakup occurs Used in selected patients with radiolucent stones in gallbladder Adverse reactions: dose related; diarrhea, anorexia, constipation, cramps, dyspepsia, epigastric distress, flatulence, heartburn, nausea, nonspecific abdominal pain, and vomiting What patient characteristics and/or history warrant the use of these agents? If the patient complains of epigastric pain, where would the pain be located? Which other drug may reduce the absorption of these medications? What type of diet education would the patient with a history of gallstones benefit from? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Digestive Enzymes Promote digestion by acting as replacement therapy when the body’s natural pancreatic enzymes are lacking, not secreted, or not properly absorbed For which clinical conditions would these enzymes be indicated? Why is proper dietary balance of fat, protein, and starch indicated for the patient who is receiving these enzymes? If the patient is receiving supplemental iron while on these enzymes, what side effect can occur? When are digestive enzymes usually scheduled to be given? What other patient education should be offered to patients taking these preparations? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Disulfiram Used in the management of alcoholism
Unpleasant reaction when combined with alcohol What symptoms would the patient experience if this drug were taken with alcohol? What physiologic condition within the body produces the disulfiram reaction? What other medication, when taken with alcohol, produces a reaction similar to the disulfiram-alcohol reaction? Why is it important for the patient to carefully read label ingredients (food, personal care items, over-the-counter medications) while on this drug? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Complementary and Alternative Therapies
Common products Conditions Drug interactions Which of these products potentiate bleeding when combined with anticoagulants, aspirin, antiplatelet drugs, or NSAIDs? Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.

Lesson 5.1: Digestion and the Digestive Organs
Through a balanced system of mechanical and chemical digestion, food is broken down into smaller substances and the nutrients are released for biological use. Special organ structures and functions accomplish these tasks through the successive parts of the overall system. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Digestion (p. 64) Basic principles Principle of change
The body cannot use food as it is eaten. Food must be changed into simpler substances to be absorbed and then used by cells to sustain life. Principle of wholeness The parts of the digestive process comprise a continuous whole. Food components travel through the gastrointestinal (GI) system until they are delivered to cells or excreted. The digestive system is highly complex. The organs work both individually and as a whole to provide nutrients to the body. What is digestion? (It is the process by which food is broken down in the gastrointestinal tract, releasing nutrients in forms that the body can use.) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Mechanical and Chemical Digestion (p. 65)
Mechanical and chemical actions make up the digestive process. Food must undergo these changes to be delivered to cells. Specific actions occurring during digestion of carbohydrates, proteins, and fats are discussed in other chapters. Digestion of each individual nutrient occurs at the same time. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Mechanical Digestion (p. 66)
Mechanical digestion: gastrointestinal motility Muscles in GI wall produce: Tonic contractions, which produce continuous movement Periodic muscle contraction and relaxation, which mix food mass and move it forward What is peristalsis? (Alternating contractions and relaxations that force food forward.) Explain the importance of rhythm in mechanical digestion. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Mechanical Digestion (cont’d) (p. 66)
Mechanical digestion: gastrointestinal motility (cont’d) Nerves from esophagus to anus: Control muscle tone in wall Regulate rate and intensity of contractions Coordinate various movements Problems with the nerves in the digestive tract can cause problems with the digestive process. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Chemical Digestion (p. 66)
Chemical digestion: gastrointestinal secretions Hydrochloric acid and buffer ions: produce the correct pH necessary for enzyme activity Enzymes: specific digestive proteins for breaking down nutrients Mucus: lubricates and protects the GI tract tissues and helps mix the food mass Water and electrolytes: carry and circulate the products of digestion through the tract and into the tissues Bile: divides fat into smaller pieces to assist fat enzymes GI secretions make chemical digestion possible. pH can affect the ability of the enzymes to work; stomach environment is acidic, small intestine environment is alkaline. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Digestion in the Mouth and Esophagus (p. 66)
Mechanical digestion Mastication breaks down food Food is swallowed and passes down esophagus Muscles at tongue base facilitate process Gastroesophageal sphincter at stomach entrance relaxes, allowing food to enter, then constricts to retain food What is mastication? (Biting and chewing) This is the start of the digestive process: breaking food into smaller pieces and moving it into the stomach. If the gastroesophageal sphincter is not working properly, acid and mixed food seep back into esophagus, resulting in heartburn. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Digestion in the Mouth and Esophagus (cont’d) (p. 66)
Chemical digestion Salivary glands secrete material containing salivary amylase or ptyalin Ebner’s glands at the back of the tongue secrete a lingual lipase Salivary glands also secrete a mucous material to lubricate and bind food particles, facilitating the swallowing of the food bolus Secretions from the mucous glands in the esophagus help move food toward the stomach What is amylase? (A starch-splitting enzyme) What is lipase? (A fat-splitting enzyme) What is a food bolus? (A lump of food material) Not much chemical change occurs in the mouth because the food does not stay there long. This is a preparatory stage to get the food ready to pass to the stomach and small intestine. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Digestion in the Stomach (p. 67)
Problems with valves and sphincters can cause reflux and discomfort. The fundus is the upper portion of the stomach. The duodenum is the first part of the small intestine. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Digestion in the Stomach (cont’d) (p. 67)
Mechanical digestion Under sphincter control, the food enters upper portion of the stomach (fundus) Stomach muscles knead, store, mix, and propel food mass forward By the time food mass reaches the lower portion of the stomach (antrum), it is a semiliquid acid/food mix called chyme Pyloric valve slowly releases chyme into the first section of the small intestine (duodenum) High-calorie foods—especially fatty foods—empty out of the stomach at a slower rate; thus the feeling of fullness lasts longer. Caloric density influences the rate in which the stomach empties. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Digestion in the Stomach (cont’d) (p. 67)
Chemical digestion: three types of acid secretions Hydrochloric acid: parietal cells in the stomach lining secrete acid to promote gastric enzyme activity Mucus: secretions protect the stomach lining from the erosive effect of the acid and also bind and mix the food mass and help move it along Enzymes: pepsinogen is secreted by stomach cells and is activated by acid to become pepsin, a protein-splitting enzyme Various sensations and emotions stimulate the nerve impulses that trigger these secretions. Anger and stress can increase secretions. Sadness and fear can decrease secretions and diminish blood flow. Ask students whether they feel more or less hungry when stressed or fearful. Do they follow these patterns? Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Digestion in the Small Intestine (p. 67)
Mechanical digestion Peristaltic waves push food forward Pendular movements stir chyme Segmentation rings chop food mass into lumps Longitudinal rotation rolls food in spiral motion, mixing it Surface villi motions stir and mix chyme What do surface villi accomplish? (They stir and mix the chyme at the intestinal wall, exposing additional nutrients for absorption.) The majority of food is digested in the small intestine. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Digestion in the Small Intestine (cont’d) (p. 68)
Chemical digestion: pancreatic enzymes Carbohydrate: pancreatic amylase converts starch to maltose and sucrose Protein: trypsin and chymotrypsin split large protein molecules into small peptide fragments and eventually into single amino acids; carboxypeptidase removes end amino acids from peptide chains Fat: pancreatic lipase converts fat to glycerides and fatty acids What organs are involved in chemical digestion? (The small intestine, pancreas, liver, and gallbladder secrete digestive enzymes and other substances.) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Chemical digestion: intestinal enzymes Carbohydrate: Disaccharidases convert disaccharides into monosaccharides. Protein: Enterokinase activates trypsinogen from the pancreas to become trypsin; amino peptidase removes end amino acids from polypeptides; dipeptidase splits dipeptides into amino acids. Fat: Intestinal lipase splits fat into glycerides and fatty acids. Ask students to explain where these enzymes originate. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Chemical digestion Mucus: protects mucosal lining Bile: emulsifying agent, aids fat digestion and absorption Hormones: secretin for alkaline environment, cholecystokinin triggers release of bile Mucus is important because the contents entering from the stomach are highly acidic. Bile breaks fat into smaller pieces so it can be broken down easier. What does secretin do? (Controls acidity and secretion of enzymes from the pancreas) Secretin keeps the environment alkaline at a pH of 8 so pancreatic enzymes can work. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Lesson 5.2: Absorption and Metabolism
Absorption, transport, and metabolism allows for the distribution, use, and storage of these nutrients throughout the body. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Absorption and Transport (p. 69)
At this point in the process: Carbohydrates: reduced to simple sugars (glucose, fructose, galactose) Fats: changed into fatty acids and glycerides Proteins: changed into single amino acids Vitamins and minerals: liberated from food When digestion is complete, food has been transformed into simple end products ready for use by cells. This transformation has prepared the food for absorption with a water base for solution and transport. Now the food is prepared for absorption as part of the GI circulation. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Absorption and Transport (cont’d) (p. 69)
Amount of nutrients consumed depends on bioavailability: Amount of nutrient present Competition between nutrients for absorption sites Form in which nutrient is present If the nutrients are not necessary, they are excreted. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Small Intestine (p. 71) Small intestine: three absorbing structures
Mucosal folds: surface of small intestine piles into many folds Villi: small, fingerlike projections Microvilli: cover each villus Make inner surface 600 times greater than outer surface of intestinal wall Each villus can receive protein and carbohydrate material as well as receive fat materials in its lymph vessels. These lymph vessels are called lacteal. If the entire surface of the small intestine were spread out, it would be half the size of a basketball court. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Small Intestine (cont’d) (p. 72)
Intestinal wall. Diagram of villi of the human intestine showing the structure and blood and lymph vessels. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Absorption Processes (p. 71)
Simple diffusion: particles move outward in all directions toward areas of lesser concentration Facilitated diffusion: uses a protein channel for carrier-assisted movement of larger particles Active transport: carrier partner (e.g., sodium) moves particles across a membrane Pinocytosis: larger materials are engulfed by a cell Small particles that do not need a protein channel use simple diffusion. An example of active transport is glucose using sodium to carry it across membranes. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Absorption in the Large Intestine (p. 73)
Water: main absorptive task of large intestine is to absorb water; small amount remains for feces Dietary fiber: contributes bulk to help form feces Macronutrients and micronutrients: absorbed to lymph or blood Only about 100 mL of water is left in the large intestine after the digestion process. Dietary fiber contributes to gas. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Transport (p. 73) Vascular system: veins and arteries Lymphatic system
Carry water-soluble nutrients, oxygen, other vital substances Transport wastes for removal Portal circulation first carries nutrients to liver for cell enzyme work Lymphatic system Carries non–water-soluble fatty materials Lymph vessels in villi absorb materials Route to larger lymph vessels Eventually to blood stream through thoracic duct The vascular system is responsible for supplying the body with nutrients, oxygen, and other vital substances. Water-soluble products of digestion can be absorbed into the vascular system. Nutrients travel to the liver by the portal circulation, then to cells throughout the body. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Metabolism (p. 73) At this point, individual macronutrients in food:
Have been broken down Absorbed into bloodstream or lymphatic system Next, nutrients can be converted into energy or stored Body is highly efficient; stores excess for later use. Explain that the body never rests, so when a person is not eating, stored energy is used. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Energy for Fuel (p. 73) Mitochondria of cells is where metabolism takes place Two forms of metabolism Catabolism: breaking down of larger substances into smaller units Anabolism: building up of larger substances from smaller units The Krebs cycle—or citric acid cycle or TCA cycle—is the hub of energy formation from food particles occurring in mitochondria. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Energy for Fuel (cont’d) (p. 73)
Metabolic processes ensure that the body has energy in the form of adenosine triphosphate (ATP) Metabolism of glucose from carbohydrates yields less energy than metabolism of fat, but glucose is the body’s primary source of energy Protein can be an energy source, but it is relatively inefficient The rate of ATP production fluctuates depending on energy needs at a given time. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Stored Energy (p. 74) Energy beyond that needed at present is stored for future Glucose is converted to glycogen via glycogenesis, stored in liver or muscles When glycogen reserves are full, excess is stored as fat via lipogenesis Excess protein/amino acids converted to glucose via gluconeogenesis If the amount of food consumed yields more energy (kilocalories) than needed, the excess is stored in the body for later use. Alcohol is not considered a nutrient but adds to overall energy intake and may be stored as fat. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Errors in Digestion and Metabolism (p. 75)
Genetic defects: cell is missing enzyme controlling metabolism of a specific nutrient Phenylketonuria (PKU) Enzyme responsible for metabolizing essential amino acid phenylalanine is missing Untreated, causes permanent mental retardation and CNS damage With proper treatment, affected children may have normal and healthy lives What foods can a person with phenylketonuria eat? Tell the students about special supplements made for this population. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Errors in Digestion and Metabolism (cont’d) (p. 75)
Genetic defects (cont’d) Galactosemia Enzyme responsible for metabolizing galactose to glucose is missing All sources of lactose must be eliminated from diet Untreated, can cause brain and liver damage Screening and treatment can enable normal life What foods would be harmful to a person with galactosemia? (Any source of lactose, such as dairy products) Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Errors in Digestion and Metabolism (cont’d) (p. 77)
Genetic defects (cont’d) Glycogen storage diseases (GSD) Group of rare genetic defects Absence of enzymes required for synthesis or breakdown of glycogen Form of disease depends on enzyme missing Because the liver is the primary site of glycogen metabolism, hepatic forms of GSD affect the entire body. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Other Intolerances or Allergies (p. 78)
Not genetic inborn errors of metabolism Rather, caused by food intolerances or allergies Lactose intolerance: deficiency of any of the disaccharidases in small intestine Insufficient lactase to break down milk Abdominal cramping and diarrhea Produces containing lactose must be avoided The higher the amount of lactose in the food, the greater the discomfort. List foods that commonly cause discomfort and foods that do not. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Other Intolerances or Allergies (cont’d) (p. 78)
Inappropriate immune responses Not necessarily a problem with digestion or metabolism Covered in Chapter 18 Allergies are an inappropriate response to an otherwise harmless substance. Ask students to name some food allergies. Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.

Chapter 5 Care of the Patient with a Gastrointestinal Disorder

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Chapter 5 Care of the Patient with a Gastrointestinal Disorder

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