Transcript Nursing and the GI System

Jane Bordner, RN BSN Nursing Instructor
HACC, Central Pennsylvania’s Community College
N100
Spring 2015
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Flexible, hollow, muscular tube
26 feet
Lined with mucous membrane
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Principle responsibility of GI tract
Occurs in mouth, stomach, and small
intestines
Majority in small intestines
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Teeth break food into smaller pieces
Saliva dilutes and softens bolus of food
Amylase begins chemical break down
Tongue:
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Made of skeletal muscle
Contains taste buds
Keeps food between teeth
Elevates to move food back into pharynx
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Passage of food from oral cavity to esophagus
Muscular tube
Constrictor muscles that contract as part of
swallowing
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Carries food from
pharynx to stomach
No digestion
Food passes through
upper esophageal
sphincter
Peristalsis pushes
food through
cardiac sphincter
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Tasks
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Produces and secretes
◦ Storage
◦ Mixing
◦ Emptying
◦ Hydrochloric Acid (HCl)
◦ Pepsin
◦ Mucus
◦ Intrinsic factor
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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
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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
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Most nutrients and electrolytes are absorbed
 Impaired
function
 Digestive process is altered
◦ Conditions such as
 Inflammation
 Ulceration
 Surgical resection
 Obstruction
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Lower GI tract/Large Colon
Bowel elimination
Larger diameter
5 to 6 feet in length
3 sections
◦ Cecum
◦ Colon
◦ Rectum
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Chyme enters through ileocecal valve
Cecum is 1st part
Colon sections
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Ascending
Transverse
Descending
Sigmoid
Rectum and Anal Canal
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4 Functions
◦ Absorption
 H2O
 Na & Cl
◦ Protection
 bacteria
◦ Secretion
 Bicarbonate and K
◦ Elimination
 Bulk waste
 Pancreas
 Liver
 Gall
bladder
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Gland
Posterior to stomach
Exocrine = secretes
pancreatic juices
◦ Amylase = CHO
◦ Lipase = Fats
◦ Trypsin = Protein and
bicarbonate
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Endocrine
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Largest organ in body
Remarkable and complex
O2 rich blood received
through hepatic arteries
Nutrient rich blood received
through portal vein
2 lobes
 Secretes
bile
 Produces bilirubin
 Removes nutrients from blood
 Stores vitamins and iron
 Converts glucose to glycogen
 Stores glycogen
 Converts
excess fatty acids and
urea
 Helps metabolize proteins, fats,
and CHO
 Detoxifies drugs and poisons
 Phagocytizes bacteria and old
RBC’s
 Stores
and concentrates bile
 Hormone CCK (cholecystokinin)
◦ secreted by intestinal mucosa
◦ stimulates gall bladder to contract and
release bile
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Disease process
Chemical/physical trauma
Social/economic factors
Stress/emotional factors
Congenital defects
Aging process
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History (SUBJECTIVE AND OBJECTIVE)
Inspection (LOOK)
Auscultation (LISTEN)
Palpation (FEEL)
Percussion
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W
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S
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Where is it?
How does it feel?
Aggravating and alleviating factors?
Timing?
Severity?
Useful other data?
Patient perception of problem?
Also include medications, nutritional assessment,
family history, cultural influences, height and
weight
RUQ
RLQ
LUQ
LLQ
 Obstruction
Series
 Upper GI/Barium Swallow
 Lower GI/Barium Enema
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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**
 EGD
 ERCP
 Sigmoidoscopy/Colonoscopy
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Eliminates need for exploratory surgery
Collection of biopsy material
Remove foreign objects
Preparation
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Post-procedure
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◦ NPO 6 to 12 hours before
◦ Use of local anesthetic to control gag reflex
◦ NPO until gag reflex returns
◦ Watch for signs of perforation and/or bleeding
post-op
Visualize colon and sigmoid area
 Empty bowel prior to test
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◦ 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
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More sensitive than x-ray
Non-invasive, no pain
May prep with contrast (clear)
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Extremely sensitive
Visualizes changes in structure and tissue
 Outlines
borders of structures
◦ liver, pancreas, gall bladder
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Amylase and lipase blood levels
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Liver enzymes (AST, ALT, LDH)
◦ Pancreatic function
◦ Liver function
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Bilirubin
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Ammonia
◦ Liver function
◦ Breakdown of RBC’s
◦ Liver function
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Albumin
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Prothrombin time
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Gastric Analysis
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Stool Exams
◦ Liver function
◦ Liver function
◦ pH
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Infection, parasites, organisms
Hemoccult (guaiac)
Consistency
Color
Odor
Anatomy and Physiology
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Where is the cardiac sphincter located?
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Where is the pyloric sphincter located?
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Where is the ileocecal valve located?
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List the 3 segments of the small intestine
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Where does most absorption of nutrients
take place?
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List 5 digestive juices and the organs that
secrete them
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Which nutrients enter the blood stream
directly?
Which nutrients enter the lymph system first?
Describe peristalsis
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List exocrine function of pancreas
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List function of gall bladder
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List functions of liver
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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)
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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
Intravenous
hyperalimentation
o Burns, trauma, malnutrition,
cancer
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Constipation
Impaction
Diarrhea
Flatulence
Incontinence
Hemorrhoids
Gastritis
Gastric Ulcer Disease
GERD
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Decreased BM
Hard, dry stool
Causes
Nursing
Interventions
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Nursing Diagnosis
Goal
Interventions
Who is at risk???
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Risk factors
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S&S
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History of constipation
Chronic confusion
Comatose
Weak and debilitated
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No BM for several days
Distended abd.
Anorexia/Nausea/Vomiting
Oozing of diarrhea stool
Feel hard fecal mass with digital exam
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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)
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Increase water in stool
Prevents straining
◦ Colace (docusate sodium)
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Side Effects
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Increase stool mass and water content
Prevent and treat simple constipation
◦ Metamucil (psyllium)
◦ FiberCon/Fiber-Lax (polycarbophil)
◦ Always give with 8 ounces of fluid
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Side Effects
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Create slippery barrier between stool and
intestinal wall
Softens impacted stool
◦ Fleets Mineral Oil
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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
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Side Effects
We know that it’s a problem
Many a thing you know you’d like to tell them
That we all too often see.
Many a thing they ought to understand
It may go on for several days
But how do you make them stay and listen to all
you say?
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?
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/fe
atured/som/music/mariasom.php
Increased number of BM’s
Loose, unformed stools
Risk for fluid and
electrolyte imbalance
Risk for skin breakdown
Nursing Diagnosis
Goal
Interventions
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Systemic Anti-Diarrheal Agents
◦ Decrease peristalsis
 Lomotil (diphenoxylate & atropine)
 Imodium (lopermide)
◦ Side effects
 Constipation
 Fatigue
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Locally-Acting Agents
◦ Absorbs water from stool
 Kaopectate (bismuth subsalicylate)
Inability to control passage of
feces and/or gas
Causes
Impact
Body image, disturbed
Risk for skin breakdown
Nursing Interventions
Bowel schedule
Meticulous skin care
S&S
Abd. pain
Abd. distention
SOA
Nursing Interventions
Increase mobility
Limit carbonation
Comfort measures
Nursing Interventions
Assess size, color and bleeding
Prevent constipation
Comfort measures
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Nausea – subjective feeling of urge to vomit
Vomiting – expelling stomach contents
May cause fluid and electrolyte imbalance
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Treat cause
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Protect airway
Monitor fluid and electrolyte balance
Provide replacement fluids (po and/or IV)
Prevent further N&V
Administer Antiemetics
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Diagnosis
Goal
Interventions
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Inhibit dopamine receptors in brain
◦ Compazine (prochlorperazine)
◦ Phenergan (promethazine)
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Side Effects
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Dry eyes and mouth
Constipation
Confusion and sedation
Extrapyramidal reactions
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Blocks effects of serotonin at receptor sites
in vagal nerve and chemoreceptors in CNS
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Anzetmet (dolasetron)
Zofran (ondansetron)
Side Effects
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Headache
Constipation
Diarrhea
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Inhibits vestibular stimulation
Used for motion sickness
Side effects
◦ Drowsiness
◦ Anorexia
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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
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CNS depressant and histamine 1 receptor
blocker
Used as adjunct to opioid analgesic
Side effects
◦ Drowsiness
◦ Dry mouth
◦ Pain at injection site
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Inflammation of stomach lining
Abd. Pain, nausea and anorexia
Interventions
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Bland diet/soft food (no caffeine, spicy food)
No smoking
Antacids
Medication to decrease stomach acid
Antiemetics
 Loss
of tissue (erosion) in mucosal
wall of esophagus, stomach or
duodenum
 Referred to as
◦ Gastric
◦ Duodenal
◦ Esophageal
◦ Stress
 Ulcers
may extend deeply into
muscle layers or through muscle to
peritoneum
◦ Etiology
 Poorly understood
 H.pylori bacteria
 May be acute or chronic
 S&S
◦ Sharp, burning, gnawing, midepigastric pain
◦ Pain occurs 1-3 hours after
meals or with meals
◦ Heartburn and belching
◦ Melena or Hematemesis
 Diagnosis
◦ Urea breath test
◦ IgG antibody for H.pylori infection
◦ Upper GI
◦ EGD
◦ Gastric secretion analysis
◦ Stools for occult blood (Melena)
◦ Gastrocult/Hematemesis
 Management
◦ Diet
◦ Rest
◦ Stress reduction
◦ No smoking or ETOH use
◦ Medication
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Back flow of stomach contents into esophagus
Incompetent cardiac sphincter
S&S
◦ Burning pain in esophagus
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Diagnosis
◦ Clinical S&S
◦ EGD
 Potential
complications
◦ Esophagitis
◦ Esophageal stricture
◦ Esophageal ulceration
◦ Barrett’s Esophagus
◦ Esophageal Cancer
 Treatment
◦ Elevate HOB
◦ Avoid acid-stimulating foods
◦ Antacids
◦ Histamine blockers (H2 receptor
antagonists)
1st line for GERD
Buffers HCL acid
◦ Maalox (magnesium & aluminum
hydroxide)
◦ Mylanta (magnesium & aluminum
hydroxide)
◦ Riopan (magaldrate)
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Side Effects
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Inhibits action of histamine at H2receptor sites in gastric parietal cells
2nd choice for GERD
Tx of peptic ulcer disease
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Zantac (ranitidine)
Pepcid (famotidine)
Tagamet (cimetidine)
Axid (nizatidine)
Side effects
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Confusion
Decrease in WBC and RBC
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Inhibit gastric secretions by blocking the
effect of histamine or acetylcholine on
receptors found in parietal cells
Tagamet
Zantac
Pepcid
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
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Prilosec (omeprazole)
Prevacid (lansoprazole)
Nexium (esomeprazole)
AcipHex (rabeprazole)
Side effects
Diarrhea
Abdominal pain
Rash (allergic reaction)
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Bind to an enzyme in the presence of acidic
gastric pH, preventing final transport of
hydrogen ions into the gastric lumen
Prilosec
Prevacid
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Used for severe GERD (Big guns)
Tx of pathological gastric hypersecretory
disorders
Adjunct tx of duodenal ulcers (Unlabeled)
Same as proton-pump inhibitors
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Protonix (pantoprazole)
Tx/prevention of duodenal ulcers
Tx of GERD (Unlabeled)
Forms a complex that adheres to ulcers;
protecting and promoting healing
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Carafate (sucralfate)
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Constipation
Dry mouth
Side Effects
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Take on empty stomach
Increased prostaglandin decreases gastric
acid and pepsin secretion and increases
protective mucus production
Use for patient on NSAIDS and ASA
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Cytotec (misoprostol)
Side Effects
Diarrhea
Abdominal pain
Miscarriage
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Tx H. pylori
Usually combo of 1 – 2 antibiotics with
proton pump inhibitor &/or H2 antagonist
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Amoxil (amoxicillin)
Biaxin (clarithromycin)
Flagyl (metromidazole)
tetracycline
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Nursing Diagnosis
Goal
Interventions
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Obstruction
Hemorrhage
Perforation
Neurological
Inflammation
Neoplasms
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Intestinal Stoma = artificial opening in
abdominal wall
Types
◦ Colostomy
◦ Ileostomy
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Assessment
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Care
◦ Stool
◦ Stoma
◦ Soap and water
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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
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Stoma picture
Transverse colostomy
Ileostomy
Ascending colostomy
Descending colostomy
Sigmoid colostomy