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