Anatomy of the Gastrointestinal Tract

Chapter 21 Nursing Assessment: Digestive, Gastrointestinal, and Metabolic Function

Anatomy of the Gastrointestinal Tract

Functions of the Digestive System
Breakdown of food particles into the molecular form for digestion Absorption into the bloodstream of small nutrient molecules produced by digestion Elimination of undigested unabsorbed foodstuffs and other waste products

Digestion Videos Chapter 21  Anatomic and Physiologic Overview of the Digestive System  Function of the Digestive System  General Digestion Chapter 21  Anatomic and Physiologic Overview of the Digestive System  Function of the Digestive System  Small Intestine Function  Digestion of Carbohydrates Chapter 21  Anatomic and Physiologic Overview of the Digestive System  Function of the Digestive System  Small Intestine Function  Metabolism of Amino Acids

Physiology of the GI System
Chewing and swallowing Gastric function Small intestine function Colon function Waste elimination

Question Which of the following physiologic processes is NOT performed in the small intestine? Breakdown of fats into absorbable particles Breakdown of carbohydrates into simple sugars Reabsorption of water and electrolytes Peristalsis

Answer Rationale: Reabsorption of water and electrolytes is the primary function of the colon. Food, initially ingested in the form of fats, proteins, and carbohydrates, is broken down into absorbable particles (constituent nutrients) by the process of digestion in the small intestine. Intestinal peristalsis propels food through the small intestine.

The Liver Can be considered a chemical factory that manufactures, stores, alters, and excretes a large number of substances involved in metabolism. Functions include: Glucose metabolism Conversion of ammonia to urea Protein and fat metabolism Vitamin and iron storage Drug metabolism Bile formation Bilirubin excretion

Liver and Biliary System (Gallbladder, Pancreas, and Spleen)

Question The exocrine functions of the pancreas are differentiated from the endocrine functions by the fact that exocrine functions involve: Secretion of enzymes Insulin synthesis Initiation of peristalsis Bile synthesis

Answer Rationale: The secretions of the exocrine pancreas are digestive enzymes high in protein content and an electrolyte-rich fluid; they include amylase, trypsin, and lipase. Insulin production is an endocrine function and the pancreas does not influence peristalsis or synthesize bile.

GI Assessment Health history Nutritional assessment Laboratory studies
Medication use

Physical Examination Video
Chapter 21  Assessment  Physical Examination  Physical Assessment: Assessing the Abdomen

Common Manifestations of GI Disease
Abdominal pain Dyspepsia Gas Nausea and vomiting Change in bowel habits and stool characteristics Jaundice Ascites Engorged veins

Physical Assessment Abdominal inspection Abdominal auscultation
Abdominal percussion Abdominal palpation Rectal examination

Diagnostic Tests Common laboratory tests include CBC, a complete metabolic panel, prothrombin time/partial thromboplastin time, triglycerides, liver function tests, amylase, and lipase Stool tests Breath tests Ultrasound DNA testing

Imaging Tests Upper GI study Lower GI study Computed tomography (CT)
Magnetic resonance imaging (MRI) Positron emission tomography (PET)

Question An elderly patient is suspected of having a chronic gastrointestinal bleed. The initial test that would address this possibility is: A PET scan Stool testing An upper GI series A lower GI series

Answer Rationale: Fecal occult blood testing (FOBT) is one of the most commonly performed stool tests. It can be useful in initial screening for several disorders, including GI bleeds. If the patient is not in distress, this would be performed prior to imaging tests.

Endoscopy Upper gastrointestinal fibroscopy/ esophagogastroduodenoscopy (EGD) Endoscopic retrograde cholangiopancreatography (ERCP) Colonoscopy Anoscopy, proctoscopy, and sigmoidoscopy Endoscopy for esophageal varices Laparoscopy Capsule endoscopy

Diagnostic Testing (cont’d)
Gastric analysis Gastric acid stimulation test pH Monitoring

Liver Function Tests Blood tests:
Measures of serum enzyme activity (serum aminotransferases, alkaline phosphatase [ALP], lactic dehydrogenase) Serum concentrations of proteins (albumin and globulins) Bilirubin Ammonia Clotting factors Lipids Liver biopsy and paracentesis

Question Is the following statement true or false? Serum bilirubin levels would be among the most relevant laboratory findings for a patient who has jaundice.

Answer Rationale: When the bilirubin concentration in the blood is abnormally elevated, all the body tissues, including the sclerae and the skin, become tinged yellow or greenish- yellow, a condition called jaundice.

NCLEX-Style Review Questions
Which assessment finding does the nurse expect as a normal consequence of aging? Increased salivation and drooling Hyperactive bowel sounds and loose stools Increased gastric production and heartburn Decreased sensation to defecate and constipation

Rationale: Older adults may lose the sensation to defecate, resulting in constipation. Salivation decreases with aging, along with peristalsis and gastric acid production.

Which of the following foods could give a false-positive result on the fecal occult blood test (FOBT)? Select all that apply. Red meats Pasta Turnips Fish Whole-grain bread

Rationale: Fish, red meats, and vegetables can produce false-positive results if consumed prior to the collection of stool for fecal occult blood testing (FOBT). Pasta and whole grain bread do not affect the results of the FOBT.

Which question will best assist the nurse in the assessment of a patient with acute diarrhea? “Have you had a colonoscopy in the last 3 months?” “Have you traveled outside the country recently?” “Do you have any trouble swallowing?” “Do you have any allergies?”

Rationale: A history of recent travel may help pinpoint an infectious source for the patient’s diarrhea. A colonoscopy will not cause acute diarrhea. Trouble swallowing is not related to diarrhea. Allergic reactions do not typically cause acute diarrhea.

The nurse recognizes that most nutrients and electrolytes are absorbed by which of the following? Esophagus Stomach Colon Small intestine

Rationale: The small intestine absorbs most of the nutrients and electrolytes. The colon absorbs water, sodium, and chloride from the digested food that has passed from the small intestine. The esophagus moves food from the mouth to the stomach, which stores food during eating and secretes digestive fluids.

When performing an abdominal assessment on a patient with suspected cholecystitis, in what sequence does the nurse palpate the patient’s abdomen? Palpate the right lower quadrant only Palpate the upper quadrants only Defer palpation and use percussion only Palpate the right upper quadrant last

Rationale: The patient with cholecystitis will report pain in the right upper quadrant of the abdomen. Tender or painful areas should be palpated last to prevent the patient from tensing his or her abdominal muscles because of pain, thereby making the examination more difficult. Palpation is an important assessment tool that should not be deferred for this patient.

Chapter 22 Nursing Management: Patients With Oral and Esophageal Disorders and Patients Receiving Gastrointestinal Intubation, Enteral, and Parenteral Nutrition

Oral Care An integral component of overall health
Primary focus of mouth care is to lessen the amount of bacterial film that accumulates on teeth, around gums, and in saliva The nurse must perform this care conscientiously if the patient is unable

Oral Disorders Video Chapter 22  Oral Disorders  Physical Assessment: Assessing the Mouth and Throat

Temporomandibular Joint Disorders
Manifestations Medical management: Surgical intervention Nursing management

Oral and Oropharyngeal Cancer
35,000 to 40,000 new cases and almost 8,000 deaths annually Risk factors include alcohol and tobacco use Management involves radiation therapy, chemotherapy, and surgery: Frequently metastasizes to the lymphatic system, necessitating neck dissection surgery

Nursing Care: The Patient With Neck Dissection Surgery
Assessments focus on altered respiratory status (airway integrity and management of secretions), wound infection, and hemorrhage Interventions prioritize protecting the airway, preventing infection, relieving pain, providing wound care, supporting nutrition, and facilitating coping and communication

Neck Dissection

Question A patient with cancer of the tongue has had a radical neck dissection. What nursing assessment would be the highest priority for this patient? Assessment of acute pain and anxiety Assessment of tissue integrity and color of the operative site Assessment of respiratory status and airway clearance Assessment of self-esteem and body image

Answer Rationale: All of the listed assessments are relevant considerations in the care of a patient who has had neck dissection surgery. However, the patient’s airway is always the priority assessment.

Esophageal Disorders Achalasia – absent or ineffective peristalsis of the distal esophagus Hiatal hernia – part of the stomach protrudes up through an enlarged opening in the diaphragm Diverticulum – an outpouching of the mucosa in a weak portion of esophageal musculature Perforation Foreign bodies Barrett’s esophagus – the esophageal mucosa is altered (usually from chronic GERD)

Gastroesophageal Reflux Disease (GERD)
May occur because of an incompetent lower esophageal sphincter, pyloric stenosis, or a motility disorder Manifestations include pyrosis (burning sensation in the esophagus), dyspepsia, regurgitation, dysphagia Treatment includes lifestyle modifications (diet, positioning), proton-pump inhibitors, and prokinetic agents (drugs that accelerate gastric emptying)

Question Is the following statement true or false? A patient who has GERD is likely to benefit from taking over-the-counter antacids after each meal.

Answer Rationale: The etiology of GERD does not involve abnormalities in the pH of gastric contents. As such, patients are unlikely to experience relief of symptoms by taking antacids.

Cancer of the Esophagus
Risk factors include male gender, alcohol and tobacco use Treatments may include surgery (esophagectomy), radiation, chemotherapy Nursing priorities after esophagectomy include nutrition promotion, prevention of aspiration pneumonia, wound care, and maintenance of the patient’s nasogastric tube

Gastrointestinal Intubation
Can be done to: Decompress (remove) stomach fluid or air Lavage the stomach and remove toxins Administer medications and nutrition Treat an obstruction Bypass sections of the tract

Types of Tubes Nasogastric and orogastric tubes – usually for decompression of the stomach; usually are large bore (12-18 Fr.) and may be single or double lumen Postpyloric tubes – continue past the stomach and enter the duodenum and jejunum; tubes are longer, smaller- bore (8-10 Fr.) and single-lumen

Nursing Management: Gastrointestinal Intubation
Preinsertion assessment Patient preparation Tube insertion Placement confirmation Securing the tube Recording fluid intake, feedings, and irrigation

Inserting the Tube Video
Chapter 22  Gastrointestinal Intubation  Nursing Management  Inserting the Tube  Nutrition: Inserting a Nasogastric Tube

Question Which of the following methods is the most accurate indication of correct GI tube placement? Instillation of air with simultaneous abdominal auscultation Abdominal X-ray Aspiration of gastric contents Gentle traction on the tube

Answer Rationale: Various methods are used to confirm tube placement. However, the most accurate method involves X-ray of the radiopaque tip of the tube.

Nursing Management: Gastrointestinal Intubation (cont’d)
Administering medications Unclogging the tube Oral and nasal hygiene Monitoring and preventing complications: Fluid volume deficit (FVD) Pulmonary complications Irritation of the mucous membranes Tube removal

Administering Tube Feedings
Given to meet nutritional requirements when oral intake is inadequate or not possible and the GI tract is functioning normally Delivered to the stomach (NG intubation or gastrostomy) or to the distal duodenum or proximal jejunum: May be a continuous or cyclic feeding schedule Priorities for care: Reducing the risk of aspiration Residual assessment Preventing dumping syndrome (highly related to the formula that is chosen)

Question Is the following statement true or false? Constipation is among the most common complications of tube feedings and appropriate nursing interventions to prevent this problem are necessary.

Answer Rationale: Diarrhea is a common complication of tube feeding and is due to the hyperosmolality of the feedings and/or the decreased serum osmolality of the patient’s serum. Constipation is a comparatively uncommon complication.

Gastrostomy A surgical procedure in which an opening is created into the stomach for the purpose of administering foods and fluids via a feeding tube Numerous advantages over NG feedings There are several types of feeding gastrostomies, including the percutaneous endoscopic gastrostomy (PEG) tube

PEG Tube

Parenteral Nutrition Indications Formulas
May be administered peripherally (peripheral parental nutrition formula [PPN]) or centrally (total parenteral nutrition [TPN]) TPN requires a central venous access device (CVAD): Nontunneled (or percutaneous) central catheter Peripherally inserted central catheter Tunneled catheter Implanted port

Subclavian Triple-Lumen Catheter

Central Method IV Access Videos
Chapter 22  Parenteral Nutrition  Administering Methods  Central Method  Central Venous Access Devices: Assessing a Peripherally Inserted Central Catheter (PICC) Site Chapter 22  Parenteral Nutrition  Administering Methods  Central Method  Central Venous Access Devices: Accessing an Implanted Port

A confused patient prematurely removes her NG tube. The nurse knows to observe for which of the following complications? Constipation Flatulence Abdominal distention Gastric bleeding

Rationale: If the tube is not replaced after its removal, the nurse should watch for abdominal distention, nausea, and vomiting. Constipation is not a complication associated with NG tube removal. Flatulence indicates air is passing through the GI tract. Gastric bleeding is not associated with removal of an NG tube, as the tubes are often soft and flexible.

The nurse is administering liquids to a patient who has recently been changed from NPO to a clear liquid diet. The patient coughs and occasionally gags with sips of water. Which health care team member would the nurse consult? Physical therapist Respiratory therapist Dietician Speech pathologist

Rationale: After the nurse stops giving the patient oral liquids, they would consult the speech pathologist for a swallowing evaluation. Physical therapists assist patients in regaining motor strength and mobility. Respiratory therapists assess and manage respiratory function and associated treatments. Dieticians evaluate the caloric needs of the patients with various illnesses and determine the correct diet to promote recovery.

A nurse is caring for a patient who is on strict bowel rest and will need IV nutrition. The nurse knows the following devices are appropriate for TPN. Select all that apply. PICC line Triple-lumen catheter Large-bore IV line Implantable venous assess device (Port-A-Cath)

Rationale: An IV line is inserted into a peripheral vein. Peripheral veins do not have the volume or velocity of blood flow to adequate dilute the TPN, a high dextrose solution, that can damage the intima of smaller vessels. PICC lines are placed in the arm and terminate in a central vein. A triple lumen catheter is commonly inserted in one of two central veins, the internal jugular or subclavian vein, Portacaths are often surgically implanted in the subclavian vein.

A nurse receives report on a patient experiencing dumping syndrome. The nurse knows that the patient would be displaying which of the following symptoms 30 minutes after eating? Difficulty swallowing Heartburn Nausea Cramping in the abdomen

Rationale: Patients with dumping syndrome are diaphoretic, dizzy, and weak. They also complain of diarrhea and abdominal cramping. The symptoms are caused by fluid shift in the intestine due to the high tonicity of the feedings. Difficulty swallowing is a common symptom of esophageal diverticulum. Heartburn is associated with GERD.

The nurse recognizes which of the following as a cause of xerostomia? Select all that apply. HIV infection Oral hypoglycemic medications Tracheostomy tube Inability to close the mouth

Rationale: Xerostomia is the decreased production or cessation of saliva production in the mouth. It is seen in patients receiving psychopharmacologic agents, patients with HIV, patients who cannot close the mouth, patients having endotracheal tubes or tracheostomy tubes, and patients with poor oral food intake. Oral hypoglycemic medications are not associated with xerostomia.

Anatomy of the Gastrointestinal Tract

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