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

3. 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

4. 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.

5. 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

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

8. 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

9. 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.

11. 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

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

14. 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.

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

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

18. 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

19. 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

20. 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

21. 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.

22. 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

23. 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

24. 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

25. 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

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

28. 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.

29. 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

30. 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.

31. 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

32. 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

33. 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

34. 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

36. 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

37. 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

38. 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.

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

41. 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.

42. 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.

43. 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