Transcript Chapter 21 Digestion and Bowel Elimination

CHAPTER 21
DIGESTION AND BOWEL
ELIMINATION
TERMS TO KNOW
Anorexia: lack of appetite
Cholelithiasis: formation or presence of gallstones
Diverticulitis: inflammation or infection of the pouches of intestinal
mucosa
Dysphagia: difficulty swallowing
Edentulous: without teeth
Esophageal dysphagia: difficulty with the transfer of food down the
esophagus
Hiatal hernia: portion of stomach protrudes through opening in
diaphragm
Oropharyngeal dysphagia: difficulty transferring food or liquid from
the mouth into the pharynx and esophagus
Presbyesophagus: age-related changes causing reduced strength of
esophageal retractions and slower transport of food
INTRODUCTION
Functions of the gastrointestinal (GI) tract (digestion
and bowel elimination)
GI problems are the source of complaints and
discomfort for older adults
Many factors impact GI health in older adults
Self-treatment can delay the diagnosis and treatment
of specific pathologies
EFFECTS OF AGING ON
GI HEALTH
Atrophy of the tongue affects taste buds and
decreases taste sensation
Saliva production decreases
Swallowing may be difficult
Presbyesophagus results in weaker esophageal
contractions and weakness of the sphincter
EFFECTS OF AGING ON GI HEALTH (CONT.)
Esophageal and stomach motility decreases
Risk for aspiration and indigestion
Decreased elasticity of the stomach
Reduces the amount of food accommodation at one
time
Stomach has higher pH as a result of decline in
hydrochloric acid and pepsin
EFFECTS OF AGING ON GI HEALTH (CONT.)
Decline in hydrochloric acid
Increase in incidence of gastric irritation
Interferes with absorption of calcium, iron, folic acid,
and vitamin B12
Decline in pepsin
Interferes with absorption of protein, iron, folic acid,
vitamin B12
Fewer cells on absorbing surface of intestinal wall
impact the absorption of dextrose, xylose, and
vitamins B and D
EFFECTS OF AGING ON GI HEALTH (CONT.)
Slower peristalsis, inactivity, reduced food/fluid intake,
drugs, and low-fiber diet
Increase in the risk of constipation
Sensory perception decreases
May lead to constipation or incomplete emptying of
the bowel
Bile salt synthesis decreases
Increase in the risk of gallstone development
Pancreas changes
Affects digestion of fats
GI HEALTH PROMOTION
Good dental hygiene and regular dental visits can
prevent disorders that threaten nutritional intake
Proper nutrition enhances general health and
minimizes the risk of indigestion and constipation
Knowledge of the impact of medications on GI health is
important
Utilization of natural means (fiber, fluids, and timing) to
promote bowel elimination
DRY MOUTH (XEROSTOMIA)
Results from:
 Decreased saliva, some medications, Sjögren’s
syndrome, mouth breathing, and altered
cognition
Consequences of decreased saliva production in the
older adult population
Interventions
Saliva substitutes, sipping water, sugarless candy
and gum
QUESTION
Which of the following interventions will promote saliva
production for the older adult living with xerostomia?
a. Prescription diuretics once a day
b. Daily oral hygiene
c. Lemonglycerin swabs every 4 hours
d. Sucking on hard sugarless candy
ANSWER
d. Sucking on hard sugarless candy
Persons with dry mouth benefit from frequent oral
hygiene, saliva substitutes, sipping water to relieve
dryness, and stimulating saliva production with hard
sugarless candy.
DENTAL PROBLEMS
Importance of dental care throughout the lifetime
Poor dentition can restrict food intake and lead to:
Constipation
Malnourishment
Impact on appearance and socialization
Impact of potential financial limitations
Encouragement of regular dental care
Specific dental problems and their potential causes
DYSPHAGIA
Incidence of swallowing difficulties increases with age
Causes
Gastroesophageal reflux disease (GERD), stroke, and
structural disorders
Nursing assessment
Goals of care and interventions:
Prevention of aspiration
Promotion of adequate nutritional status
QUESTION
Which of the following medical problems may result in
dysphagia?
a.
b.
c.
d.
Hypertension
GERD
Osteoporosis
Diverticulosis
ANSWER
b. GERD
GERD is a common cause of dysphagia, as well as stroke
or structural disorders of the GI system.
HIATAL HERNIA
Incidence: increases with age, affects about half of
people in the U.S. over age 50 years, >older women
Causes: may be low fiber diet
Types
 Sliding (axial)
 Rolling (paraesophageal)
Signs and symptoms: heartburn, dysphagia, belching
vomiting, regurgitation, pain-may be severe and mistaken for
a heart attack
Diagnosis: barium swallow and esophagoscopy
Treatment/management: medically, weight reduction, bland
diet, milk, antacids, avoid eating right before bed, sleeping
partially recumbent, medications
ESOPHAGEAL CANCER
Incidence: decreasing, but most persons affected are of
advanced age (50-70 y/o, >men)
Types: squamous cell and adenocarinoma
Causes: alcoholism, heavy smoking, poor oral hygiene and
chronic irritation from tobacco, alcohol and other agents,
Barrett’s esphogus
Signs and symptoms: dysphagia, weight loss, excessive
salivation, thirst, hiccups, anemia, chronic bleeding
Diagnosis: Barium swallow, esophagoscopy, & biopsy
Treatment/management: surgical resection, radiation,
chemotherapy, laser therapy
PEPTIC ULCER DISEASE
Predisposing factors: diet, stress, genetic predisposition, longevity
Causes: complication of COPD, medications (ASA, reserpine,
tolbutatmide, colchicine, adrenal corticosteroids), smoking,
alcohol, caffeine, H pylori infection
Signs and symptoms: present with more acute symptoms-pain,
bleeding, obstruction, and perforation
Complications: constipation or diarrhea caused by antacid therapy
and pyloric obstruction-resulting in dehydration, peritonitis,
hemorrhage, and shock
Diagnosis: Upper GI series (EGD), CBC, & addressing risk factors
Treatment/management: antacid therapy, antibiotics if bacteria is
cause
CANCER OF THE STOMACH
Incidence/prevalence: 50-70 y/o, >men, poor
socioeconomic groups; adenocarcinomas account for
most gastric malignancies
Signs and symptoms: anorexia, epigastric pain, weight
loss, & anemia-may be insidious and easily mistaken
for indigestion issues, bleeding, & enlarged liver
Diagnosis: barium swallow, gastroscopy & biopsy
Treatment/management: surgery-partial or total
gastrectomy; prognosis is good if detected early
Prevention: diet low in red meat and high in antioxidants
may be helpful
DIVERTICULAR DISEASE
Diverticulum, diverticulosis, and diverticulitis
Incidence: very common among older adults
Causes: chronic constipation, obesity, hiatal hernia, &
atrophy of the intestinal wall muscles with aging; low
fiber, low residue diet common in Western societies are
a major reason for commonality
Signs and symptoms of each condition: if present may be
slight bleeding, a change in bowel habits, tenderness in
left lower quad
Treatment/management: diagnosed with barium enema,
medical management is most common (increasing
dietary fiber, weight reduction, and avoidance of
constipation)
QUESTION
Is the following statement True or False?
Overeating, straining during a bowel
movement, alcohol, and irritating foods
may contribute to diverticulitis in the
patient with diverticulosis.
ANSWER
True
Bowel contents can accumulate in the diverticula
and decompose, causing inflammation and
infection which is considered diverticulitis.
Overeating, straining during a bowel movement,
alcohol, and irritating foods may contribute to
diverticulitis in the patient with diverticulosis.
COLORECTAL CANCER
Second most common malignancy in the United States
Signs and symptoms: bloody stools, change in bowel habits,
anorexia, nausea, pain over affected region, anemia;
often ignored due constipation, poor diet or hemorrhoids
Diagnosis and diagnostic tests: digital rectal examination
detects half of all carcinomas of the large bowel and
rectum, occult blood-for early detection of colonic tumors;
barium enema and sigmoidoscopy with biopsy to confirm
Treatment/management: surgical resection with colostomy
Impact of a colostomy on an older adult: adjustment to body
changes, embarrassing episodes, reduced energy
reserves, arthritic fingers, slower movement, poor
eyesight, dependency on others…
CHRONIC CONSTIPATION
Contributing or causative factors: inactive lifestyle, low
fiber and low fluid intake, depression, laxative abuse,
certain medications, dulled sensations that cause
signal for bowel elimination, failure to allow enough
time for complete emptying
Interventions to promote bowel elimination: high fiber
diet, regular activity, some particular foods
Need for education
 Safe use of laxatives, some herbs may be helpful
Use of an elimination chart : hospital and nursing home
May require medical evaluation: if no improvement with
the usual measures
FLATULENCE
Causes: constipation, irregular bowel movements, certain
foods, and poor neuromuscular control of the anal
sphincter
Discomfort may occur if there is an inability to expel flatus
Treatment/management: achieving regular bowel patterns,
avoid flatus-producing foods, medications, sitting
upright after meals to allow gas to rise to the fundus of
the stomach
Interventions: increasing activity, knee-chest position,
flatus bag
INTESTINAL OBSTRUCTION
Causes: diverticulitis, ulcerative colitis, hypokalemia,
vascular problems, paralytic ileus
Types
Partial or complete
Large intestine: cancer
Small intestine: adhesions and hernias
Signs and symptoms
Vary depending on the site and cause:
SBO- upper and mid abdominal pain, vomiting
Past the ileum-severe abdominal distention
Colon-lower abdominal pain, altered bowel habits,
distension, and a sensation of the need to defecate
INTESTINAL OBSTRUCTION (CONT.)
Nursing assessment
 Careful attention to bowel sounds
 High-pitched peristaltic rushes
 May be decreased or absent if obstruction has persisted for a
long time or if there has been significant damage
Treatment/management
 Timely intervention is extremely important to avoid strangulation
of the bowel
 Medical management-NGT
 Surgical management-if due to vascular or mechanical
obstruction
QUESTION
Nursing evaluation and assessment of an older adult
with a new-onset bowel obstruction will demonstrate
what type of bowel sounds?
a. Hypoactive bowel sounds
b. High-pitched bowel sounds
c. Absence of bowel sounds
d. Presence of limited bowel sounds
ANSWER
b. High-pitched bowel sounds
Bowel obstruction can cause high-pitched peristaltic
rushes heard with auscultation. If the bowel obstruction
has persisted for a long time, or the bowel has been
significantly damaged, bowel sounds decrease and
eventually are absent.
FECAL IMPACTION
Prevention of constipation aids in avoiding fecal
impaction
A bowel elimination record is essential-frequency and
character of bowel movements
Signs and symptoms: distended rectum, abdominal and
rectal discomfort, oozing, fever, palpable, hard fecal
mass
Diagnosis: see signs and symptoms
Nursing interventions
Important to follow agency policy-manual removal, oil
retention enema
BOWEL INCONTINENCE
Involuntary defecation
Inability to voluntarily control the passage of stool
Most often associated with fecal impaction
First step: assess for impaction
Other causes: decreased contractile strength, agerelated sphincter weakness, reduced reservoir
capacity (secondary to resection or tumor)
Diagnosis: proctosigmoidoscopy, proctography,
anorectal manometry
Treatment/management: the cause dictates the
treatment; which may include bowel retraining
ACUTE APPENDICITIS
Infrequent in older adults
Atypical presentation: severe pain may be absent, pain
may be minimal and referred, fever may minimal,
leukocytosis may be absent
Potential for a delay in diagnosis
Potential for greater complications and mortality
Treatment/management: emergency surgery
CANCER OF THE PANCREAS
Difficult to detect
Diagnosed at an advanced stage
Signs and symptoms: anorexia, weakness, weight loss, and
wasting-easily attributed to other causes; dyspepsia,
belching, nausea, vomiting, diarrhea, constipation and
obstructive jaundice may also occur, epigastric pain
radiating to back (worse in recumbent position)
Diagnosis: ERCP, CT scan, MRI, Ultrasound, laparoscopy,
and biopsy
Treatment/management: surgery
Generally poor prognosis due to advanced disease
QUESTION
Is the following statement True or False?
Signs and symptoms of pancreatic cancer include
anorexia, weakness, weight loss, dyspepsia,
belching, nausea, and vomiting.
ANSWER
True
Anorexia, weakness, weight loss, and wasting are
generalized symptoms of pancreatic cancer easily
attributed to other causes. Dyspepsia, belching,
nausea, vomiting, diarrhea, constipation, and
obstructive jaundice may also occur.
BILIARY TRACT DISEASE
Cholelithiasis (gallstones)
Incidence increases with age, women>men
Signs and symptoms: Pain
Treatment/management: non surgical therapies
(lithotripsy); standard surgical procedures
Cancer of the gallbladder
Signs and symptoms-pain RUQ, anorexia, nausea,
vomiting, weight loss, jaundice, weakness, constipation
Does not occur frequent
Surgery may be performed
Poor prognosis
SUMMARY
GI symptoms need to be taken seriously
Diagnosis of specific conditions/diseases can be
difficult
Careful assessment is extremely important