Medical-Surgical Nursing: Concepts & Practice 3rd edition Chapter 27 The Gastrointestinal System Copyright © 2017, Elsevier Inc. All rights reserved.

Chapter 27 Objectives Discuss the various functions of the GI system List major causative factors in the development of disorders of the GI system Summarize measures to prevent these disorders Determine nursing responsibilities in pre and post test care of patients undergoing diagnostic tests for disorders of the GI system

Clinical Practice Objectives Perform an assessment of gastrointestinal status. Provide pretest and post-test care of patients undergoing tests of the liver, gallbladder, and pancreas. Provide care for a patient who is experiencing vomiting. Teach patient strategies to alleviate constipation.

Gastrointestinal System Structures and functions of different organs Gastrointestinal tract – mouth, pharynx, esophagus, stomach, small intestine, large intestine, rectum and anus Gastroesophageal spincter – controls the opening from the esophagus into the stomach- prevents reflux Stomach – upper left portion of the abdominal cavity Small intestine – duodenum, jejunum and ileum Large intestine – decum, colon, rectum, anal canal Appendix – attached to cecum – has no know function in the digestive process

Organs of the Digestive System See Figure 27-1 on p. 625.

Effects of Aging on the GI System page 626 Esophageal sphincter becomes less efficient – risk for aspiration increases Taste buds atrophy After 70 years, parietal cells in the stomach decrease their secretion of HCL; enzyme and intrinsic factor secretion also decrease. Small intestine mucosa absorbs less, large intestine dimished motility

Structures and functions of accessory organs pge 626 Liver – manufactures and secretes bile, synthesizes albumin, fibrogen, globulins and clotting factors. All nutrients and oral medications pass through the liver. Responsible for how drugs are metabolized.

Structures and functions of accessory organs page 626 Gallbladder – stores bile produced in the liver and delivers it as needed to the small intestine; the gallbladder can store up to 50 ml of bile. Pancreas – produce hormones insulin and glucagon into the blood; insulin is essential to the metabolism of carbohydrates

Accessory Organs of the Digestive System See Figure 27-2 on p. 625.

Effects of Aging on the Acessory Organs Gallstone incidence is higher in older adults, tendency towards dehydration. Pancreas secretion of lipase decreases – altering fat digesion.

The Stomach See Figure 27-3 on p. 626.

Absorptive and Storage Functions of the Large Intestine See Figure 27-4 on p. 626.

Causes of Gastrointestinal Disorders pg 627 Infection, inflammation, physical and chemical trauma, and structural defects Surgery complications-scar tissue Psychological and emotional stresses Genetic predisposition, familial tendency, and ethnic correlation Immune disorders

Causes of Accessory Organ Disorders Gallbladder - Risk factors associated with gallbladder disease- rapid weight loss, age, DM, Crohn disease, family history Prevention of gallbladder disorders – normal body weight, avoid rapid weight loss diets, alcohol in moderation, remain active

Risk Factors Associated with Liver Disorders page 628 Liver disorders – filters out many toxic substances- constantly exposed to infectious organisms in bloodstream. Hepatitis virus attacks the liver Liver Cancer – Hep B and Hep C. May be primary or secondary to metastasis Cirrhosis of the liver – drugs, chemicals, alcohol, parasites. See table 27-1 page 629 Prevention – immunizations against Hep A and B (no vaccine for Hep C) avoid above

Risk Factors Associated with Pancreatic Disorders page 629 Pancreatitis – inflammation Causes – alcoholism, peptic ulcer, hyperlipidemia and trauma, age Pancreatic cancer- smoking, DM, obesity, chronic pancreatitis Prevention – moderation alcohol, removing of gallbladder that has gallstones to prevent obstruction causing pancreatitis.

Audience Response Question 1 The nurse discussing disease prevention measures to a group of older adults during a senior seminar should include which instruction(s)? (Select all that apply.) Consume sufficient fiber. Eat a normal, well-balanced diet. Exercise regularly. Drink at least three glasses of fluids. Take laxatives regularly. Correct Answer: 1, 2, and 3

Diagnostic Tests and Procedures –Table 27-1 Radiography Computed tomography (CT) scans Nuclear medicine scans Magnetic resonance imaging Ultrasound studies Endoscopy Biopsy Laboratory tests Tests of gastric secretions Stool and urine studies

Nursing Implications of Diagnostic Tests Check the patient’s allergies. A pregnancy test might be ordered. Patient teaching Diet, including NPO (nothing by mouth) status and dehydration Psychological care

Assessment (Data Collection) see page 636 Family history Diet and dietary intolerances Presence of pain Problems with blood clotting Verify immunization status Comprehensive history of illnesses and exposure to toxic agents

Auscultate Bowel Sounds in All Four Quadrants See Figure 27-5 on p. 636.

Ascultating Bowel Sounds The normal frequency for bowel sounds is about…….??? 5 to 30 in one minute Loud, frequent sounds occur when there is excessive motility in the bowel For bowel sounds to be considered absent – no sounds after listing in each quadrant for 5 minutes. Hypo – no sounds after listening in each quad for 30 seconds.

Anorexia – absence of appetite Any time a patient has continual problems with eating – dental history and oral cavity exam should be performed. Also check for difficulty swallowing. Depression. Taste and smell senses diminish with age

Anorexia – absence of appetite Mouth care Monitor laboratory results. Document percentage of each meal eaten. Psychosocial or cultural factors Include a variety of colors, textures, and tastes. Nursing assignments to unlicensed assistive personnel – assist with meals to encourage eating.

Nausea and Vomiting Interferes with with eating and hinders nutrition Smells that exacerbate nausea – strong scents Ginger for nausea – may decrease the action of histamine receptor antagonists

Accumulation of Flatus Surgery, mechanical obstruction, accidental injury – peristalsis is decreased or flow of chime is inhibited by obstruction. Ambulation…Exercise to reduce gas and bloating Medications - simethicone

Constipation Identify the cause of constipation – diet low in fiber, dehydration, opiod medications, some neurologic disorders. Rectal suppository or enema Stool softener Raw fruits and vegetables Acceptable exercise program

Older Care Points Constipation Decreased GI motility, lack of exercise, limited fluid intake, constipating medications. Reliance on laxatives common among older adults Need more dietary fiber and increased fluids

Diarrhea Antidiarrheal agents Mild – no treatment Moderate – more than 24/48 hours – Lomotil Kaopectate, clear liquids Severe diarrhea- NPO until it subsides, prolonged may require TPN Probiotics for infectious diarrhea

Nursing Management of Diarrhea Monitor intake and output. Administer ordered medications. Replace lost fluids. Monitor the patient for electrolyte imbalances and watch for signs of dehydration. Avoid coffee and tea. Thorough hand hygiene Standard Precautions

Bowel Incontinence Severe illness, trauma, neurologic damage, or prolonged bed rest Keep the patient clean and dry. Tracking the time of incontinent movements and offering toileting after each meal may help eliminate the problem. If incontinence is persistent, the cause should be identified and then a bowel training program instituted.

C diff Antibiotics kill harmful bacteria, but also kill normal intestinal flora. Clostridium difficile (C.diff) may develop. Isolation precautions implemented.

Bowel Training The patient should be in a private environment 20 to 40 minutes after a meal and assume a normal sitting position for defecation if possible or a side-lying position if bedridden. The nurse or patient performs digital stimulation by gently inserting and rotating a gloved, well-lubricated finger into the rectal sphincter. This action should be done on a regular basis to mimic the patient’s normal bowel pattern.

Bowel Training (Cont.) A warm drink or prune juice may also help to stimulate the bowels. Consistency and patience are vital to the success of retraining the bowel. In accordance with National Patient Safety Goals, encourage patients to call for help during bowel training. Reassure patients that calling for help ensures safety and provides an opportunity to observe the progress of the training program.

Audience Response Question 2 An older female patient of Puerto Rican descent was admitted for persistent anorexia and dehydration. With no apparent organic underlying cause for loss of appetite, which action(s) would be culturally appropriate? (Select all that apply.) Determine food preferences. Encourage family visits. Provide warm beverages with meals. Consider parenteral nutrition. Consult a dietitian and speech therapist. Correct Answer: 1, 2, and 3