Transcript Digestive Tract: Let`s Get to the Bottom of it

Digestive Tract: Let’s Get to the
Bottom of it
By: Diana Blum RN MSN
Metropolitan Community College
Primary Role

Extract molecules essential for cellular
function from fluids and food.
Ingestion, Digestion, Absorption, Elimination

Digestion: breakdown of food into simple
nutrient molecules that can be used by cells

Process requires:
 1.
 2.
 3.
http://health.discovery.com/centers/digestive/machine.html
Digestive tract

Also called ___________tract
muscular tube about 30 ft long
 Main parts

 Mouth
 Pharynx
 Esophagus
 Stomach
 Small
intestine
 Large intestine
 Anus
Acessory Organs






Salivary glands
Liver
Gallbladder
Pancreas
Each of the above accessory organs secrete fluid
that contain special enzymes that enable
breakdown (metabolism) of food
Peritoneum lines the abdominal cavity and covers
surface of organs

Enables organs to moves without friction during
breathing and digestion
mouth
Teeth cut and grind food
 Salivary glands secrete saliva

Saliva:
 Amylase:


Tongue mixes saliva with food and when
small enough- forces the food into the
pharynx
Pharynx
Shared by digestive and respiratory tracts
 Joins mouth and nasal passages
 Contains the epiglottis


Covers the airway (like a trap door) to prevent
food from entering respiratory tract
esophagus
Long muscular tube that passes through the
diaphragm into the stomach
 Gravity helps move the food but it is not
essential
 Circular, wave like contractions of the
muscles propel food down the tract
(peristalsis)

Stomach




Widest section of the GI tract
Separated from esophagus by the cardiac sphincter
Has 3 sections
Unique muscle layers churn food by mixing it with gastric
secretions






Rennin-starts breakdown of milk proteins
Pepsin-partially digests protein
HCL acid-partially digests protein
Lipase-breaks down fat
Chyme:
Pyloric sphincter- keeps food in stomach until it is mixed
properly
Small Intestine
Chyme leaves stomach and enters here
 Chemical digestion and absorption of
nutrients take place
 20 feet long
 3 sections

Duodenum-liver and pancreatic enzymes enter
here
 Jejunum
 Ileum

Small Intestine Continued



Bile- produced in the liver and stored in the GB
break down large fat globs
Pancreatic enzymes-reduce the fat to glycerol and
fatty acids to be easily absorbed
3 layers of tissue make up the wall




Mucous membrane-secretes digestive enzymes
Sucrase, lactase, maltase, lipase, etc. (see table 36-1)
Inner layer- covered with Villi (microscopic projections).
Digestive food molecules are absorbed through the villi
into the bloodstream
Muscle layers continue to contract moving the chyme into
the large intestine.
Large Intestine





No Villi
No digestive enzymes
Chyme enters through the ileocecal valve
Water is absorbed and remaining waste=feces
5 sections




Cecum-1st section..appendix is here
Ascending colon-up right abdomen
Transverse colon- across abdomen just below waist
Descending colon-down the left abdomen



Sigmoid colon-the part of the descending colon between iliac
crest and rectum
Rectum-the last 6-8 inches of the large intestine
Anus – where waste leaves the body
Age related changes
















Teeth mechanically worn down
Illness causes increased risk for problems with digestion/elimination
Gingiva recedes
Tooth loss from caries and periodontal disease
Loss of taste buds
Xerostomia (dry mouth) is common
Walls of esophagus and stomach are thinner with lessened secretions
HCL Acid and digestive enzyme production decreases
Gastric motor activity slows
Delayed gastric emptying
Hunger contractions diminish
In the large intestine- muscle layer and mucosa atrophy
Smooth muscle tone and blood flow decreases
Connective tissue increases
Constipation is frequent
More laxative use
Nursing Assessment






Hx of illness: weight loss, indigestion, change in bowel habit
PMH: surgery, trauma, infection, burns, hepatitis, ulcers,
cancer, stomas, meds, allergies
Fam Hx: diabetes, CA, ETOH, polyps, obesity, ulcers, GB
Dx
System Review: flatus, dyspepsia (indigestion), skin
changes, caries, diff chewing, abd distention, pain,
elimination
Functional: nutrition, activity, meal times, likes/dislikes, food
beliefs
Physical exam: mucous membranes, condition of
mouth/teeth, abd distention, bowel tones, palpation,
percussion, rectum/anus for lesions, color, hemorrhoids
diagnostics

Imaging/radiographs: NPO, allergy (iodine,
dye, shellfish), consent
UGI
 Barium swallow/enema
 Endoscope

 Upper
 Lower

Hemmocult-looks for blood

NG
Salem Sump
Tube feedings

Assist pt into fowlers to reduce aspiration.



Pt remains up at least 30 degree during continuous feeding
Check placement for tube in stomach or duodenum prior to
use





Remains this way for 30 minutes after
Air bolus and residual
Check to make sure you have the correct formula
Stop feeding if nausea or pain
Rinse tube with 30 cc fluid after each bolus
Administration




Remove plunger
Pinch tube while inserting syringe to avoid stomach content leak
Hold barrel about 12 inches above stomach and allow gravity to
infuse
Flush after bolus complete
GI decompression

Ng with suction


removes fluid and gas
To use

Attach to sxn as ordered








Generally low, intermittent is used for single tube
Low continuous for dual lumen tubes
Check patency
Irrigate routinely
Monitor output
Assess for flatus
Provide comfort measures
Once tube in place- securely tape it to nose
feedings

TPN

Deliver nutrients directly
into bloodstream via
central line




Use sterile technique for
dressings and care
Monitor flow rate
Monitor blood glucose
Label lines


PPN
Same as TPN except
goes through
peripheral line
Anorexia
Lack of appetite
 Causes

Nausea
 Physical/emotional disturbances
 Environment
 Decreased sense of smell


Tests: weight, physical, hemoglobin, iron,
electrolytes, thyroid
Nursing diagnosis
Imbalanced nutrition less than requirements
r/t anorexia
 Goal: improved appetite and adequate food
intake
 AEB: increase in intake, stable or increased
wt
 Interventions: provide antiemetics prior to
meals, remove the bed pan and emesis
basin from sight, conceal drains and
collection devices, deodorize room

clients with Feed problems
Paralyzed
 Confused
 Severe arthritis
 CVA
 Visually impaired
 Etc


FEEDER is demeaning and can threaten self
esteem
Interventions for feed problem
Position properly
 Specially enhanced utensils
 Open sealed products
 Cut meats
 Butter bread
 Season food after asking client their
preferences
 See page 751

Role play
Practice feeding classmate a simple meal then
reverse.
The person being fed can not speak but
understands what is being said
1.How did it feel to be fed?
2. What steps did you use?
3. How did the feeder feed?
4. What did you learn?
Stomatitis

Inflammation of the oral mucosa
Mechanical trauma (poor fitting dentures)
 Irritation 2nd to smoke and ETOH
 Poor hygiene
 Radiation
 Drug therapy

Treatment: soft bland diet, antiviral agents,
antibiotics
Vincent’s
infection
(aka Trench
Mouth)
Vincent’s infection
Caused by bacteria
 Called trench mouth b/c occurred in WWI
field
 S/S: metallic taste foul breath. Bleeding
ulcers, increased saliva, general infection
signs, anorexia
 TX: topical antibiotics, mouthwash, rest,
nutritious diet, good oral hygiene

Herpes Simplex
Herpes Simplex
Caused by Herpes simplex virus type 1
 S/S: ulcers and vesicles in mouth and on lips
 Other name is cold sore or fever blister
 Common with people who have upper
respiratory infections, excessive sun
exposure, or are stressed
 TX: Camphor, topical steroids, antiviral
agents

Aphthous Stomatitis
(aka canker sore)
Caused by virus
 S/S: ulcer on lips or
mouth that recur at
intervals
 TX:topical or systemic
steroids

Candidas Albicans
AKA yeast like fungus
Other names: thrush or
candidiasis
 S/S: bluish white lesions on
mucous membrane of mouth
 Those at risk: steroid users,
long term antibiotic users
 TX: oral medications, topical
antifungal agents, vaginal
nystatin tablets can be used
like lozenges

Care and intervention

CARE


Usually tx outpt
Look at pt symptoms


Onset of symptoms,
meds, radiation, habits,
diet, ETOH use, and
smoking

INTERVENTION




Describe pain (location,
onset, precipitating
factors)

Gentle oral hygiene
Prescribed mouthwash
Use soft bristle tooth
brush
Instruct to take meds as
prescribed (swish and
spit, or swish and
swallow)
Teach flossing
techniques
Dental Caries


Destructive process of
tooth decay
Caused by plaque



Plaque is made from
bacteria, saliva, and cells that
stick to tooth surface
In time if untreated the
canal will erode causing
intense pain and death of
pulp
TX: fluoride, good nutrition
Gingivitis




Beginning of
periodontal dx
Inflammation of the
gums
s/s: red inflammed
tissue of gums, pain,
bleeds easily
More frequent in those
with missing teeth or
whose teeth don’t close
properly, vitamin
deficiency, anemia
Care and Intervention

CARE



Assess pain and
soreness
Assess diet and
examinations
Examine mouth care
practices

INTERVENTION



Minimize pain
Gentle mouth care
several times a day
Teach client proper
technique

Page 752
Oral Cancer


Most life threatening condition
of mouth
2 types:




Squamous
Basal cell
S/S: tongue irritation, loose
teeth, tongue pain, ulcerations,
leukoplakia (hard white spots),
decreased appetite, diff
swallowing, weight loss, change
in denture fit, hemoptysis
TX: biopsy, surgery, radiation,
chemo
Care and Intervention

CARE

Assess sun exposure, smoking
habits, ETOH use, fam hx of oral
ca,

Interventions

Radiation=edema













Dry mouth is issue
Good hygiene
Special rinses see pg 753
Monitor respirations
Suction if ordered
Stay on top of pain
Soft or liquid diet
Monitor I/O
Use communication board to talk
with pt
BE PATIENT
BE A GOOD LISTENER
Monitor for infection
If graft: monitor color and temp
Parotitis





Inflamed parotid glands
S/S: painful swelling near
low jaw, pain increases
with mastication
Suseptible: those unable to
drink liquids, those weak,
no resistance to infection
TX: antibiotics, mouthwash,
warm compress
Complications: gland
ruptures, surgical drainage
or removal may be
necessary
Achalasia
Progressive
worsening dysphagia
 Low esophageal
muscles do not relax
 Unknown cause
 TX:dilation, surgery,
botulism toxin,
isosorbide dinitrate

Esphageal cancer





Not common
Poor prognosis
No known cause
At risk: smokers, ETOH users,
chronic trauma, poor oral
hygiene, spicy food eaters
S/S: progressive dysphagia,
substernal pain, epigastric pain,
neck/back pain,sore throats,
choking, obstruction, weight loss
Esophageal treatment

Esophagectomy
Esophagogastrostomy
Esophagoenterostomy
Dilitation of esophagus
Stent
Laser tx
Chemo
Radiation
Photodynamic therapy

See page 756








Interventions













Treat pain
Daily weight
Strict I/O
Calorie count
Quiet relaxed environment
Erect position
Chin tuck maneuvers for swallowing
Feeding tubes
TPN
If post op---do not irrigate or reposition
Assess pt knowledge
Monitor for infection
Monitor respirations
N/V

Nausea: feeling of queasiness








Pain, pallor, perspiration, cold, clammy skin
Causes: irritating foods, infection, radiation, meds, inner ear disorders,
motion sick
Vomiting: forceful expulsion of stomach content through the mouth
Regurgitation: gentle ejection of fluid or food w/o nausea or retching
TACHYCARDIA AND INCREASED SALIVA are common before
vomiting
Complications: loss of fluid and electrolytes, dehydration, metabolic
alkalosis, weakness, aspiration
TX: antiemetics, iv fluids, NG tube
Interventions: maintain cool room, remove unpleasant stimuli, place in
comfortable position, provide emesis basin, cool damp cloth on
head/neck, slow deep breaths, offer mouth care after vomiting, clear
liquids
Hiatal Hernia


Protrusion of stomach and and lower esophagus up
thru the diaphragm and into chest
2 types:







Sliding: gastroesophageal junction is just above the
hiatus. Stomach slides when patient reclines
(associated with GERD)
Rolling: gastroesophageal junction remains in place
but a portion of the stomach herniates up throu
diaphragm through a 2nd ary opening
Complications: ulcerations, bleeding, aspiration
Strangulated hernia is one that becomes trapped
without blood flow
Causes: asymptomatic to fullness, dysphagia,
eructation (belching), regurgitation, heartburn
TX: meds(antacids, H2 receptor blockers, etc), diet,
avoid intra abd pressure, surgery
Interventions: stay on top of pain, no food or fluid 23 hours before bed, wooden blocks under top of
bed, monitor wt, small frequent meals, avoid fatty
foods, caffeine, ETOH, and spicy foods
GERD






Back flow of gastric content from the stomach into the
esophagus
Key find: inappropriate relaxation of the low esophagus
sphincter
Causes: abnormalities in the LES, ulcers, esophageal
surgery, prolonged vomiting, gastric intubation
S/S: can be sudden or gradual, painful burning that
moves up and down (common after meals) resolve
after antacids, dysphagia, belching
Diagnosis: Based on s/s, raqdiographic studies,
endoscopy, bx
Tx: H2 receptor blockers (zantac), prokinetic agents
(reglan), proton pump inhibitors (prilosec), surgery
Gastritis





Inflammation of the stomach
lining
Mucosal barrier that normally
protects stomach breaks down
H pylori is cause
S/S: N/V, anorexia, fullness,
pain, hemorrhage
Tx: npo until resolve, IVF, Bx,
medication,, bland diet,
surgery
Peptic Ulcer







Loss of tissue from digestive lining
Caused by pepsin and HCL injure
unprotected tissue
LOCATION, LOCATION, LOCATION
 Either gastric or duodenal
Causes: drugs, infection, stress.
S/S: burning pain, nausea, anorexia,
wt loss
Complication: hemorrhage, perforation,
obstruction,
Tx: meds, diet, stress management

Drug therapy
Used to relieve symptoms
 Antacids are first line of defense


Diet
Avoid coffee, tea, meat broth, alcohol, spicy food
 Frequent small feedings


Management
NG tube to sxn if hemorrhage suspected
 Saline lavage after NG procedure on page 769772
 Vasopressin may help control hemorrage


Table 38-6 discusses surgery tx of peptic
ulcer dx
Stomach cancer







25,000 dx each year
Most common in men, african
americans, people over 70, low
socioeconomic status
S/S: no early signs
Late signs: vomiting, ascites, liver
enlargement, abd mass
5 yr survival: 10%
No known cause
Risk factors: pernicious anemia,
chronic atrophic gastritis, achlorhydria
(lack of HCL), smoking, high salt starch
pickled food nitrate diet
obesity




Excess body fat
Causes: heredity, body build,
metabolism, psychosocial,
caloric intake
Complications: heart/lung
problems, DM, polycythemia,
cholelithiasis, infertility,
endometrial cancer, DJD
Tx: wt reduction diet, exercise,
medication (pg775), surgery,
malabsorption





1 or more nutrients not absorbed/digested
Causes: bacteria, bile salt and digestive enzyme deficiency, alterations
in intestinal mucosa
2 types:
 Celiac sprue (tropical, nontropical)- genetic,
 Non-Tropical: changes in mucosa, impaired absorption
 Tropical: infectious agent
 Lactose intolerance
 Inherited or aquired
 Causes: IBS, gastroenteritis, sprue syndrome
S/S: steatorrhea (fatty stools), foul stools, wt loss,
decreased libido, easy bruising, edema, anemia, bone pain
Tx: diet, meds, elimate gluten for celiac dx


Tropical sprue: oral folate, antibx, vit B12 injections
Lactose: no milk or milk products, lactase enzyme, monitor vitamin
levels
diarrhea





Loose liquid stools
Causes: spoiled foods, allergies,
infection, diverticulosis, cancer,
malabsorption, impactions, tube
feedings, medications
S/S:cramps, abd pain, urgency
Complications: dehydration,
electrolyte imbalance
Tx: anti diarrheal drugs, clear
liquids vs npo, possible TPN
constipation



Hard dry infrequent stools
Causes: ignoring urge, laxative
use, inactivity, inadequate fluid
intake, drugs, brain/spinal cord
injury, colon diseases, surgery,
Tx: laxatives, stool softeners,
megacolon

Large intestine
looses ability to
contract to move
feces to rectum

Pts need regular
enemas
Fecal impaction
Retention of large amount of stool in the
rectum
 Some liquid passes around
 TX: Digital exam/extraction

Intestinal obstruction




Causes by strangulated
hernia, tumor, ileus, stricture,
volvulus (twisting of bowel)
S/S: vomiting (bile, blood,
feces), abd pain, constipation
Complications: electrolyte
imbalances, gangrene,
perforation, shock, death
TX: gastric decompression,
IVF, surgery
appendicitis




Blind patch in the cecum
Inflammation of opening of
appendix-bacteria related
s/s: pain especially at
mcburney’s point (1/2 way b/w
umbilicus and iliac crest),
fever, n/v, elevated WBC
Tx: NPO, cold pack
peritonitis


stomach contents enter Abd cavity
Complications: fluid shift, abscesses,
adhesions, septicemia, hyovolemic
shock, ileus, organ failure

S/S: abd distention, increased pulse
and RR, n/v, fever, rigid abd, shock

TX: NG for gastric decompression,
IVF, antibiotics, pain meds, surgery
IBS






2 types:
 Ulcerative colitis:
 Begins in rectum, expands to cecum
 Crohn’s: regional enteritis
 Affects all GI tract
 Most common= terminal ileum
Causes: unknown
S/S of IBS: constipation, diarrhea, bloody stools, abd
cramping, wt loss
S/S crohn’s: variable, n/v, pain, cramping, abd
tenderness, fever, night sweats, malaise, joint pain
Complications:hemorrhage, obstruction, perforation,
abscess, fistulas, megacolon, colon cancer, joint
inflammation, diarrhea, stones, liver dx, electrolyte
imbalances
Tx: meds (page 786), low roughage diet without milk,
nicotine patches, surgery with possible removal of
intestine
Diverticulosis






Small sac like pouches in intestinal wall
Most in sigmoid colon
Risk factors: lack of dietary factors, age,
constipation, obesity, emotional tension
S/S: asymptomatic, constipation,
diarrhea, pain, rectal bleed, n/v, urinary
problems
Complications: bleed, obstruct,
perforation, peritonitis, fistula
Tx: high residue diet, no spicy foods, no
seedy food, stool softener, meds, page
788, surgery
Colorectal CA





3rd most common in women
High fat low fiber diet is risk factor
Most found in rectum or low
sigmoid
S/S: depend on location,
cramping, anemia, weakness,
fatigue, left sided= more obvious
changes
TX: surgery, colostomy, chemo,
radiation
Polyps





Small benign growths that can become
malignant
Multiple polyps called gardner’s
syndrome or familial polyposis
S/S:asymptomatic
Complications: bleed, obstruction
Tx: removal, colectomy
hemorrhoids





Dilated veins in rectum
May be internal or external
Risk factors: increased
pressure in rectal blood
vessels from constipation,
pregnancy, prolonged sit or
stand
S/S: pain, bleed, itching,
TX : surgery, ice followed by
heat, medication
Anorectal abscess



Infection in the tissue around
rectum
S/S: pain, swelling, redness,
tenderness, diarrhea,
bleeding, itching, discharge
Tx: antibx, incision, drainage,
surgery, ice packs, pt
education r/t to cleansing
Anal fissure

Laceration b/w anus and
perianal skin

r/t constipation, diarrhea,
crohn’s, TB, leukemia, trauma,
childbirth
S/S: pain with defecation,
bleeding, itching, urinary
frequency, urinary retention,
dysuria
Tx: heal spontaneously, sitz
bath, stool softeners, pain
meds, surgery


Anal fistula




Abnormal opening b/w anal canal and
perianal skin
Causes: abscess, IBD, TB
S/S: pruritis, discharge
Tx: sitz bath, surgery, temporary
colostomy, pain meds
Pilonidal cyst



Painful and
swollen
May form
abscess
Surgery may be
needed to fix
PT EDUCATION
Handwashing
 Proper food handling
 Food poisoning
 Stress management
 When to call doctor
 Page 793


THE END