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Transcript of Jane Bordner, RN BSN Nursing Instructor HACC, Central Pennsylvania’s Community College N100 Spring...
Gastrointestinal System
Jane Bordner, RN BSN Nursing InstructorHACC, Central Pennsylvania’s Community
CollegeN100
Spring 2015
Anatomy and Physiology
Flexible, hollow, muscular tube 26 feet Lined with mucous membrane
GI Tract
Principle responsibility of GI tract Occurs in mouth, stomach, and small
intestines Majority in small intestines
Digestion
Teeth break food into smaller pieces Saliva dilutes and softens bolus of food Amylase begins chemical break down Tongue:
◦ Made of skeletal muscle◦ Contains taste buds◦ Keeps food between teeth◦ Elevates to move food back into pharynx
Oral Cavity
Passage of food from oral cavity to esophagus
Muscular tube Constrictor muscles that contract as part of
swallowing
Pharynx
Esophagus Carries food from
pharynx to stomach No digestion Food passes
through upper esophageal sphincter
Peristalsis pushes food through cardiac sphincter
Tasks◦Storage◦Mixing◦Emptying
Produces and secretes◦Hydrochloric Acid (HCl)◦Pepsin◦Mucus◦Intrinsic factor
Stomach
Segmentation Peristalsis 7 to 10 L of liquid moves through in one day Chyme is reduced to a volume of 600 to 800
ml that is paste-like consistency
Small Intestine
3 Sections:◦ Duodenum – 2 feet long
Continues to process chyme◦ Jejunum – 5 feet long
Absorption of CHO and protein◦ Ileum – 12 feet long
Absorption of H2O, fat, and bile salts Most nutrients and electrolytes are
absorbed
Small Intestine
Impaired functionDigestive process is altered
◦Conditions such as Inflammation Ulceration Surgical resection Obstruction
Small Intestine
Lower GI tract/Large Colon Bowel elimination Larger diameter 5 to 6 feet in length 3 sections
◦ Cecum◦ Colon◦ Rectum
Large Intestine
Chyme enters through ileocecal valve Cecum is 1st part Colon sections
◦ Ascending◦ Transverse◦ Descending ◦ Sigmoid
Rectum and Anal Canal
Large Intestine
4 Functions◦Absorption H2O Na & Cl
◦Protection bacteria
◦Secretion Bicarbonate and K
◦Elimination Bulk waste
Large Intestine
Accessory Structures of Digestion
PancreasLiverGall bladder
Gland Posterior to stomach Exocrine = secretes
pancreatic juices◦ Amylase = CHO◦ Lipase = Fats◦ Trypsin = Protein and
bicarbonate Endocrine
Pancreas
Pancreatic Duct
Largest organ in body Remarkable and complex O2 rich blood received
through hepatic arteries Nutrient rich blood received
through portal vein 2 lobes
Liver
Secretes bile Produces bilirubin Removes nutrients from bloodStores vitamins and ironConverts glucose to glycogenStores glycogen
Liver Functions
Converts excess fatty acids and urea
Helps metabolize proteins, fats, and CHO
Detoxifies drugs and poisons Phagocytizes bacteria and old RBC’s
Liver Functions
Stores and concentrates bileHormone CCK (cholecystokinin)
◦secreted by intestinal mucosa◦stimulates gall bladder to contract and release bile
Gall Bladder
Factors that Affect GI Function Disease process Chemical/physical trauma Social/economic factors Stress/emotional factors Congenital defects Aging process
Assessment
History (SUBJECTIVE AND OBJECTIVE) Inspection (LOOK) Auscultation (LISTEN) Palpation (FEEL) Percussion
Assessment of GI Status
W - Where is it? H - How does it feel? A - Aggravating and alleviating factors? T - Timing? S - Severity? U - Useful other data? P - Patient perception of problem?
Also include medications, nutritional assessment, family history, cultural influences, height and weight
History
Inspection (LOOK)
Auscultation (LISTEN)
Palpation (FEEL)RUQ LUQ
RLQ LLQ
Percussion
Diagnostic Studies
Obstruction SeriesUpper GI/Barium SwallowLower GI/Barium Enema
Radiological Exams
Upper GI Series
Lower GI/Barium Enema
◦ Light, low fat, low residue diet for 2 days◦ Clear liquid dinner evening before◦ NPO after midnight◦ Stimulant laxative night before◦ Enemas until clear or Colyte/Golytely prep
**Bowel must be clean of stool for accurate results**
Patient Prep
EGDERCPSigmoidoscopy/Colonoscopy
Endoscopy – Flexible scope
Eliminates need for exploratory surgery Collection of biopsy material Remove foreign objects Preparation
◦NPO 6 to 12 hours before◦ Use of local anesthetic to control gag reflex
Post-procedure◦NPO until gag reflex returns◦ Watch for signs of perforation and/or bleeding
post-op
EGD(Esophagogstrodudenscopy)
ERCP (Endoscopic Retrograde Cholangiopancreatography)
Visualize colon and sigmoid area Empty bowel prior to test
◦Bowel Prep 2 day prep (outpatient) Clear liquid diet for 1 - 2 days Enema until clear or Go-lytley prep
◦IV sedation may be used during procedure
◦Patients find this test intrusive
Sigmoidoscopy/Colonoscopy
More sensitive than x-ray Non-invasive, no pain May prep with contrast (clear)
CT Scan
Extremely sensitive Visualizes changes in structure and tissue
MRI
Outlines borders of structures ◦liver, pancreas, gall bladder
Ultrasound
Amylase and lipase blood levels◦ Pancreatic function
Liver enzymes (AST, ALT, LDH)◦ Liver function
Bilirubin◦ Liver function◦ Breakdown of RBC’s
Ammonia◦ Liver function
Laboratory Studies
Albumin◦ Liver function
Prothrombin time◦ Liver function
Gastric Analysis◦ pH
Stool Exams◦ Infection, parasites, organisms◦ Hemoccult (guaiac)◦ Consistency◦ Color◦ Odor
Laboratory Studies
GI System ReviewAnatomy and Physiology
Where is the cardiac sphincter located?
Where is the pyloric sphincter located?
Where is the ileocecal valve located?
List the 3 segments of the small intestine◦ _____________________◦ _____________________◦ _____________________
Where does most absorption of nutrients take place?
List 5 digestive juices and the organs that secrete them◦ _________________ ___________________◦ _________________ ___________________◦ _________________ ___________________◦ _________________ ___________________◦ _________________ ___________________
Which nutrients enter the blood stream directly?
Which nutrients enter the lymph system first?
Describe peristalsis
List exocrine function of pancreas
List function of gall bladder
List functions of liver◦ ___________________________________________◦ ___________________________________________◦ ___________________________________________◦ ___________________________________________◦ ___________________________________________◦ ___________________________________________◦ ___________________________________________◦ ___________________________________________
Therapeutic Uses of Salem Sump Tube
Remove gas and fluids from stomach (decompression)
Obtain gastric secretions for analysis
To relieve/reduce obstructions or bleeding
Promote healing after surgery – prevent strain on sutures
Remove toxic substances (lavage with poisonings)
Assessing Placement Ask client to speak Inspect pharynx Instill 15 – 30 ml of
air while listening over stomach
Aspirate gastric contents◦ Assess color◦ Assess pH
Gastric secretions: < 4
Assessing Drainage Irrigation
Total Parenteral Nutrtion
o Intravenous hyperalimentationo Burns, trauma, malnutrition, cancer
Common ProblemsConstipationImpactionDiarrheaFlatulenceIncontinenceHemorrhoids GastritisGastric Ulcer DiseaseGERD
Constipation Decreased BM Hard, dry stool Causes Nursing
Interventions
Nursing Diagnosis Goal Interventions Who is at risk???
Constipation
Risk factors◦ History of constipation◦ Chronic confusion◦ Comatose◦ Weak and debilitated
S&S◦ No BM for several days◦ Distended abd.◦ Anorexia/Nausea/Vomiting◦ Oozing of diarrhea stool◦ Feel hard fecal mass with digital exam
Fecal Impaction
Fecal Impaction
Constipation TreatmentStimulants Stimulates peristalsis Pulls fluid into stool Used for bowel prep Used for acute
constipation
◦Side Effects Pain/cramps Diarrhea Dehydration
◦Examples magnesium citrate Milk of Magnesia
(MOM) Senokot
(sennosides) Dulcolax
(bisacodyl)
Increase water in stool Prevents straining
◦ Colace (docusate sodium) Side Effects
Stool Softeners
Increase stool mass and water content Prevent and treat simple constipation
◦ Metamucil (psyllium)◦ FiberCon/Fiber-Lax (polycarbophil) ◦ Always give with 8 ounces of fluid
Side Effects
Bulk-Forming Laxatives
Create slippery barrier between stool and intestinal wall
Softens impacted stool◦ Fleets Mineral Oil
Lubricants
Uses osmotic pressure to draw water into stool
Used for bowel cleansing or occasional constipation◦ Colyte/Go-Lytely (polyethylene glycol/electrolyte)◦ Miralax (polyethylene glycol)◦ Fleet Enema, Fleet Phospho-Soda
(phosphate/biphosphate Side Effects
Osmotics
SongWe know that it’s a problem
That we all too often see.
It may go on for several days
Sometimes it worries me
Yes, it’s a private matter
But I can clearly see
We just don’t do enough ‘bout constipation.
We listen to heir bowel sounds and we ask them how they feel
We make sure they have lots to drink with each and every meal.
I hate to have to say it, but I very firmly feel: We just don’t do enough ‘bout constipation!
I’d like to say a word on our behalf. Constipation is a pain in the ……
How do you help the soul with constipation?
How do you keep their bowel from standing still? How do you treat the soul with constipation? An enema? A suppository? A pill?
Many a thing you know you’d like to tell them
Many a thing they ought to understand
But how do you make them stay and listen to all you say?
How do you make them comply with the plan?
Oh how do you help the soul with constipation? We must prevent impaction if we can!
When they’re rushed and when they’re hurried
When they’re stressed and when they’re worried
And they don’t eat a healthy foods they way they should
Then they come in when they’re sick, And their bowels don’t move a lick
Then we give them opioids, O that’s not good!
“cuz it slows down their digestion, causing problems without question
But they need it for their pain and that’s a fact.
So we give them Senekot, some will take it, some will not, document it when they go and what you got!!
(REPEAT CHORUS)
http://www.sunnycorner.com/movies/featured/som/music/mariasom.php
Diarrhea
Increased number of BM’sLoose, unformed stoolsRisk for fluid and electrolyte imbalanceRisk for skin breakdown
Nursing DiagnosisGoalInterventions
Diarrhea
Anti-Diarrheal Medications
Systemic Anti-Diarrheal Agents◦ Decrease peristalsis
Lomotil (diphenoxylate & atropine) Imodium (lopermide)
◦ Side effects Constipation Fatigue
Locally-Acting Agents◦ Absorbs water from stool
Kaopectate (bismuth subsalicylate)
Incontinence
Inability to control passage of feces and/or gasCausesImpact
Body image, disturbed
Risk for skin breakdownNursing Interventions
Bowel scheduleMeticulous skin care
Flatulence
S&SAbd. painAbd. distentionSOA
Nursing InterventionsIncrease mobilityLimit carbonationComfort
measures
Hemorrhoids
Nursing InterventionsAssess size, color and bleedingPrevent constipationComfort measures
Nausea – subjective feeling of urge to vomit
Vomiting – expelling stomach contents May cause fluid and electrolyte imbalance
Treat cause
Nausea and Vomiting
Protect airway Monitor fluid and electrolyte balance Provide replacement fluids (po and/or IV) Prevent further N&V Administer Antiemetics
Nursing Interventions for N&V
Diagnosis Goal Interventions
Nursing Diagnosis for N&V
Inhibit dopamine receptors in brain◦ Compazine (prochlorperazine)◦ Phenergan (promethazine)
Side Effects◦ Dry eyes and mouth◦ Constipation◦ Confusion and sedation◦ Extrapyramidal reactions
Phenothiazines
Blocks effects of serotonin at receptor sites in vagal nerve and chemoreceptors in CNS
◦ Anzetmet (dolasetron)◦ Zofran (ondansetron)
Side Effects◦ Headache◦ Constipation◦ Diarrhea
5-HT3 antagonists
Inhibits vestibular stimulation Used for motion sickness Side effects
◦ Drowsiness◦ Anorexia
Dramamine (dimenhydrinate)Anivert (meclizine)
Blocks dopamine Increases GI motility Prevention of chemo induced N&V Tx of gastric stasis and post-op N&V Side effects
◦ Drowsiness ◦ Restlessness◦ Extrapyramidal reactions
Reglan (metoclopramide)
CNS depressant and histamine 1 receptor blocker
Used as adjunct to opioid analgesic Side effects
◦ Drowsiness◦ Dry mouth◦ Pain at injection site
Vistaril (hydroxyzine)
Inflammation of stomach lining Abd. Pain, nausea and anorexia Interventions
◦ Bland diet/soft food (no caffeine, spicy food)◦ No smoking◦ Antacids◦ Medication to decrease stomach acid◦ Antiemetics
Gastritis
Loss of tissue (erosion) in mucosal wall of esophagus, stomach or duodenum
Referred to as◦Gastric ◦Duodenal◦Esophageal◦Stress
Peptic Ulcer Disease
Ulcers may extend deeply into muscle layers or through muscle to peritoneum◦Etiology Poorly understood H.pylori bacteria May be acute or chronic
Peptic Ulcer Disease
S&S◦Sharp, burning, gnawing, mid-epigastric pain
◦Pain occurs 1-3 hours after meals or with meals
◦Heartburn and belching◦Melena or Hematemesis
Peptic Ulcer Disease
Diagnosis◦Urea breath test◦IgG antibody for H.pylori infection◦Upper GI◦EGD◦Gastric secretion analysis◦Stools for occult blood (Melena)◦Gastrocult/Hematemesis
Peptic Ulcer Disease
Management◦Diet◦Rest ◦Stress reduction◦No smoking or ETOH use◦Medication
Peptic Ulcer Disease
Back flow of stomach contents into esophagus Incompetent cardiac sphincter S&S
◦ Burning pain in esophagus Diagnosis
◦ Clinical S&S◦ EGD
GERD
Potential complications◦Esophagitis ◦Esophageal stricture◦Esophageal ulceration◦Barrett’s Esophagus◦Esophageal Cancer
GERD
Treatment◦Elevate HOB◦Avoid acid-stimulating foods◦Antacids◦Histamine blockers (H2 receptor antagonists)
GERD
Gastric Medications
1st line for GERD Buffers HCL acid
◦ Maalox (magnesium & aluminum hydroxide)
◦ Mylanta (magnesium & aluminum hydroxide)
◦ Riopan (magaldrate) Side Effects
Antacids
Inhibits action of histamine at H2-receptor sites in gastric parietal cells
2nd choice for GERD Tx of peptic ulcer disease
◦ Zantac (ranitidine)◦ Pepcid (famotidine)◦ Tagamet (cimetidine)◦ Axid (nizatidine)
Side effects Confusion Decrease in WBC and RBC
Low-dose Histamine H-2 Antagonist
Inhibit gastric secretions by blocking the effect of histamine or acetylcholine on receptors found in parietal cells
Tagamet Zantac Pepcid
H2 inhibitors (Blockers)
3rd choice for GERD Tx of duodenal ulcers Prevention of GI bleeding in critically ill ICU pt. Binds to an enzyme on gastric parietal cells in
presence of acidic gastric pH, preventing final transport of H ions into gastric lumen
◦ Prilosec (omeprazole)◦ Prevacid (lansoprazole)◦ Nexium (esomeprazole)◦ AcipHex (rabeprazole)
Side effects◦ Diarrhea◦ Abdominal pain◦ Rash (allergic reaction)
Proton-Pump Inhibitors
Bind to an enzyme in the presence of acidic gastric pH, preventing final transport of hydrogen ions into the gastric lumen
Prilosec Prevacid
Proton Pump Inhibitors
Used for severe GERD (Big guns) Tx of pathological gastric hypersecretory
disorders Adjunct tx of duodenal ulcers (Unlabeled) Same as proton-pump inhibitors
◦ Protonix (pantoprazole)
Gastric Acid Pump Inhibitor
Tx/prevention of duodenal ulcers Tx of GERD (Unlabeled) Forms a complex that adheres to ulcers;
protecting and promoting healing◦ Carafate (sucralfate)
Side Effects◦ Constipation◦ Dry mouth
Take on empty stomach
GI Protectant
Increased prostaglandin decreases gastric acid and pepsin secretion and increases protective mucus production
Use for patient on NSAIDS and ASA◦ Cytotec (misoprostol)
Side Effects◦ Diarrhea ◦ Abdominal pain◦ Miscarriage
GI Prostaglandin
Tx H. pylori Usually combo of 1 – 2 antibiotics with
proton pump inhibitor &/or H2 antagonist◦ Amoxil (amoxicillin)◦ Biaxin (clarithromycin)◦ Flagyl (metromidazole)◦ tetracycline
Antibiotics
Nursing Diagnosis Goal Interventions
Nursing Diagnosis for PUD
Miscellaneous Topics
Obstruction Hemorrhage Perforation Neurological Inflammation Neoplasms
Pathology of GI Tract
Intestinal Stoma = artificial opening in abdominal wall
Types◦ Colostomy◦ Ileostomy
Assessment◦ Stool ◦ Stoma
Care◦ Soap and water
Intestinal Stomas
Colostomies And Ileostomies◦Patient may lose up to 1000 ml/day of fluid through ileostomy
◦Patients should avoid high fiber foods because of increase in GI transit time
◦May be temporary or permanent
Intestinal Stomas
Stoma picture
IleostomyAscending colostomy
Transverse colostomy
Descending colostomy Sigmoid colostomy
Nursing Diagnosis
Nursing Care