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The Gastrointestinal System: Digestive Disorders

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1 The Gastrointestinal System: Digestive Disorders
Part I Developer’s note regarding this Power Point Presentation: This presentation on the Gastrointestinal System, Part I, is designed to be WATCHED in the “Slide Show” mode. *In general the slides will progress automatically within each slide—you are ready to click and view the next slide when the “arrow button” appears in the bottom right of each page. The one slide that requires “extra clicks is slide 17, which is a concept map related to the GI System & Nursing Care. *Please note that the hyperlinks work, but ONLY work when the presentation is in Slide Show mode. Certain portions of the presentation are designed as print out capability, i.e., the Medication Slides, though most of it , again, is designed to be “watched.” --Jerry Enjoy! J. Carley MSN, MA, RN, CNE “Air-Fluid Levels” seen in small bowel obstruction

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3 The G-I System Supplemental Learning Objects:
Flash Cards (Terminology) See the I sent you yesterday G-I System Games Meds for the Gastro Intestinal System G-I System Part I GI System Part 2 G-I System Part 3

4 LEARNING OUTCOMES At the conclusion of this learning activity, the nurse will be able to:
1. Describe the mechanism of action, signs and symptoms, complications, treatments and nursing interventions for gastrointestinal disorders 2. Compare and describe the pathophysiology for Crohn’s Disease and ulcerative colitis 3. Explain pathophysiology, types, risk factors, and treatment for gastritis

5 4. Explain the use of radiography in diagnosis of GI health problems
LEARNING OUTCOMES At the conclusion of this learning activity, the nurse will be able to: 4. Explain the use of radiography in diagnosis of GI health problems 5. Discuss the physical assessment findings in a client with digestion, nutrition, and elimination health problems 6. Describe procedures, risk factors, potential complications, nursing monitoring, and interventions for scope procedures

6 9. Apply the nursing process to medication administration and usage
LEARNING OUTCOMES At the conclusion of this learning activity, the nurse will be able to: 7. Describe preparation, post-op interventions, and teaching needs for a patient with a new colostomy 8. Analyze medications, usage, precautions, side effects, and mechanism of action 9. Apply the nursing process to medication administration and usage

7 12. Explain causes of bowel obstruction
LEARNING OUTCOMES At the conclusion of this learning activity, the nurse will be able to: 10. Explain causes, sign/ symptoms, nursing interventions, treatments, and complications of a bowel obstruction 11. Explain pathophysiology, risk factors, and medical management of gastrointestinal disorders 12. Explain causes of bowel obstruction

8 A Rough Outline: For the Left Hemispheric Dominant Learners
Terminology A&P GI Disorders GERD Hiatal Hernias PUD G-I Pharmacology Antacids Prokinetic Agents H 2 Receptor Antagonists Proton Pump Inhibitors Mucosal Barriers G-I Diagnostic Testing

9 Key Terms & word roots* -algia -dynia volvulus dyspepsia regurgitation
hypersalivation pyrosis eructation dysphagia odynophagia -enter/o -col/o -gastr/o -esophag/o ulceration aspiration ischemia diverticula diverticulitis colostomy illeostomy tenesmus steatorrhea diarrhea fistula defecation --rrhea steato-

10 Anatomy and Pathophysiology
Length = 27-30 feet (9-10 meters)

11 GI Tract Functions Secretion Digestion Absorption Motility Elimination

12 CN X: Vagus Nerve Involves: esophagus, stomach, small intestines, gallbladder, and large intestines Parasympathetic: stimulates motor and secretory activity, relaxes sphincters

13 Oral Cavity Teeth: chewing Mucin and amylase: breaks down food Tongue
Pharynx Esophagus: 2 sphincters

14 Esophagus

15 Stomach

16 Function of Stomach Ingestion of food Food reservoir
Digestive process: -movement -gastrin secretion: hydrochloric acid and pepsin -chyme

17 GI Disorders

18 ***Diagnostic Testing Disease Specific Medications:
Concept Map: Selected Topics in Gastro-Intestinal Nursing Pathophysiology PHARMACOLOGY ASSESSMENT Physical Assessment Inspection Palpation Percussion Auscultation KEY ASSESSMENTS Lab Monitoring Upper GI Lower GI Anti-Acids (Antacids) Prototype: aluminum hydroxide gel (Amphojel) Inflammatory Inflammatory G.E.R.D. Peptic Ulcers Gastric Ulcers Duodenal Ulcers Gastritis Prokinetic Agents: Prototype: metoclopramide (Reglan) Acute Appendicitis Peritonitis Ulcerative colitis Crohn’s Disease Diverticulitis Histamine 2 Receptor Agonists Prototype: ranitidine hydrochloride (Zantac) ***Diagnostic Testing Proton Pump Inhibitors) Prototype: omeprazole (Prilosec) Non-Inflammatory Non-Inflammatory G.E.R.D. Hiatus Hernias Constipation & Diarrhea Irritable Bowel Syndrome Dumping Syndrome Intestinal Obstruction Hemorrhoids & Polyps Malabsorption Mucosal Barriers Prototype: sucralfate (Carafate) Disease Specific Medications: Care Planning Plan for client adl’s, Monitoring, med admin., Patient education, more…based On Nursing Process: A_D_O_P_I_E ***Preparing for Diagnostic Tests Nursing Skills: NG Tube Insertion Enteral Feedings Nursing Interventions & Evaluation Execute the care plan, evaluate for Efficacy, revise as necessary

19 GI Disorders Inflammatory Non-Inflammatory Upper GI
Gastroesphageal Reflux Disease Ulcers Gastritis Upper GI Gastroesphageal Reflux Disease Hiatus Hernia/hernias

20 GI Disorders Inflammatory Non-inflammatory Lower GI Acute Appendicitis
Peritonitis Ulcerative colitis Crohn’s Disease Diverticulitis Lower GI Constipation & Diarrhea Irritable bowel syndrome Dumping syndrome Intestinal Obstruction Hemorrhoids and polyps Malabsorption syndrome

21 The Inflammatory Process
Acute local inflammation: -edema, pain, heat, and redness -exudates may or may not be present Acute systemic inflammation: -fever -leukocytosis (increased WBC) -plasma protein synthesis

22 Inflammatory Process Chronic Inflammation:
-increased duration>2 weeks -proceeds after unsuccessful acute inflammatory response -may occur without distinct inflammation

23 Overview: Gastroesophageal Reflux Disease (GERD)
GERD : common condition (affects 14% of Americans) characterized by gastric content and enzyme leakage into the esophagus. These corrosive fluids irritate the esophageal tissue and limit its ability to clear the esophagus. Causes are related to the weakness or transient relaxation of the lower esophageal sphincter (LES) at the base of the esophagus, or delayed gastric emptying. The chief symptom of GERD is frequent and prolonged retrosternal heartburn (dyspepsia) and regurgitation (acid reflux) in relationship to eating or activities. Other symptoms can include chronic cough, dysphagia, belching (eructation), flatulence (gas), atypical chest pain, and asthma exacerbations.

24 Gastroesophageal Reflux Disease (GERD)
Backward flow of gastrointestinal contents into esophagus

25 Cause of GERD Inappropriate relaxation of lower esophageal sphincter (food, medication, etc)

26 GERD: Etiology ETIOLOGY: CONTIBUTING FACTORS:
Excessive ingestion of foods that relax LES, e.g., fatty / fried foods, chocolate, tomatoes, alcohol Distended abdomen from overeating or delayed emptying Increased abdominal pressure resulting from obesity, pregnancy, bending at the waist, ascites or tight clothing at the waist Drugs that relax the LES, such as theophylline, nitrates, calcium channel blockers, anticholinergics, and diazepam (Valium) Drugs, such as NSAIDs, or events (stress) that increase gastric acid Debilitation or age-related conditions resulting in weakened LES tone Hiatal hernia (LES displacement into the thorax with delayed esophageal clearance) Lying flat ETIOLOGY: Any factor that relaxes the LES, such as smoking, caffeine, alcohol, or drugs. Any factor that increases the abdominal pressure, such as obesity, tight clothing at the waist, ascites, or pregnancy. Older age and/or a debilitating condition that weakens the LES tone.

27 Signs & Symptoms of GERD
Classic symptoms: Dyspepsia, especially after eating an offending food / fluid, and regurgitation. Other symptoms: Symptoms from throat irritation (chronic cough, laryngitis), hypersalivation, eructation, flatulence, or atypical chest pain from esophageal spasm. Chronic GERD can lead to dysphagia (difficulty swallowing).

28 Complications of GERD Irritation to esophagus and mucosal injury
Aspiration Barrett’s esophagus Esophageal erosions, ulcerations, or tears Chronic bronchitis Asthma (adult onset) Barrett’s Esophagus

29 Diagnostic Testing History and Physical Dietary monitoring
24 hour ambulatory pH monitoring Esophageal manometry Endoscopy

30 Diagnostic Interventions : GERD
Barium Upper GI: Prepare the client for the procedure. Post procedure: Assess for bowel sounds and potential constipation. Endoscopy : Conscious sedation to observe for tissue damage Post procedure: Verify gag response prior to providing oral fluids or food.

31 Barium Sulfate (Ba SO4)

32 Medical Management for GERD Non-surgical
Goals: relief of symptoms and prevent complications Life style changes: -Diet: smaller meals more frequent, limit or avoid carbonated beverages, coffee, chocolate, fats, mints, spicy or acidic food

33 Medical Management Continued
Life Style Changes: -Elevate HOB, sleep on LEFT side -AVOID smoking and ETOH -Avoid tight or restrictive clothing -Lose weight

34 Medical Management Proton Pump inhibitors (PPI) Other Medications
Antacids, E.g., aluminum hydroxide (Mylanta), neutralize excess acid. -- should be administered when the acid secretion is highest (1 to 3 hr after eating and at bedtime). --Antacids should be separated from other medications by at least 1 hr. Histamine 2 (H2) receptor antagonists E.g., ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid), and cimetidine (Tagamet), reduce the secretion of acid. The onset is longer than antacids, but the effect has a longer duration. Proton Pump inhibitors (PPI) E.g., pantoprazole (Protonix),omeprazole (Prilosec), esomeprazole (Nexium), and lansoprazole (Prevacid) reduce gastric acid by inhibiting the cellular pump necessary to secrete it. Studies show that PPI are more effective than H2 antagonists. Other Medications E.g., metoclopramide hydrochloride (Reglan), increase the motility of the esophagus and stomach.

35 Invasive Interventions for GERD
Endosopic therapy: BESS (Bard EndoCinch Suturing System), Stretta, and Enteryx procedures Surgery: Laparoscopic Nissen Fundoplication (The”Gold Standard”)

36 Nursing Interventions
Post operative or procedure management: - Monitor vital signs -Monitor swallow/gag reflex -Assess for abdominal pain -Monitor for bleeding -Assess incision sites -Assess and monitor NG tube

37 Nursing Diagnosis Altered Nutrition Acute or Chronic pain
Risk for aspiration Alteration in sleep patterns Knowledge Deficit Impaired Swallowing Potential for complications

38 Nursing Interventions
EDUCATION: -Medication Compliance -Dietary changes -Lifestyle changes Post operative or procedure management

39 Normal Esophagus

40 GERD

41 Barrett’s Esophagitis

42 Hiatal Hernia Involve protrusion of the stomach wall through the esophageal hiatus of the diaphragm

43 Types of Hiatal Hernias
Sliding: (Most Common) esophagogastric junction and portion of the fundus slide upward through the esophageal hiatas Rolling: the fundus and portions of the stomach rolls through the esophageal hiatas

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45 Causes of Hernias Muscle weakness Anatomic defects Congenital weakness
Prolonged increased abdominal pressure Surgery Trauma Obesity

46 Symptoms of Hernias Adult onset asthma Symptoms worse after meals
Sliding Rolling Adult onset asthma Symptoms worse after meals Symptoms worse in recumbent position Feeling full after eating Breathlessness or feeling of not be able to breath Chest pain like angina feeling of suffocation Symptoms worse in recumbent position

47 Diagnostic Testing Barium Swallow Study

48 Medical Management Diet Medications (GERD) Weight Loss
Avoid late night food Avoid straining/vigorous exercise No restrictive or binding clothes Surgical repair: Laparoscopic Nissen Fundoplication

49 Nursing Interventions
Education: -Medication compliance -Dietary changes and monitoring -Lifestyle changes and monitoring Post-op management Assess coping mechanisms

50

51 Peptic Ulcer Disease (PUD)
A mucosal lesion of the stomach or duodenum

52 PUD Causes Results when gastric mucosal defenses become impaired and no longer protect the epithelium from the effects of acid and pepsin

53 Types of PUD Gastric Ulcers:
-a break in mucosal barrier, hydrochloric acid injures epithelium -back diffusion of acid or dysfunction of the pyloric sphincter -Mucosal Inflammation Duodenal Ulcers: -increase acid content dumped into duodenum

54 Types of PUD “Stress Ulcers:”
-Unknown etiology, presence of increased levels of hydrochloric acid, ischemia, and erosive gastritis seen -Trauma, head injuries, respiratory failure, shock sepsis

55 Signs and Symptoms Intermittent sharp, burning, or gnawing pain
Gastric pain occurs to the left and may be relieved by food A change in appetite with or weight loss (gastric) Nausea or vomiting Bloody stools

56 Signs and Symptoms Frequent burping or bloating
Duodenal pain is usually to the right of the epigastruim and pain occurs 90 min-3 hours after eating. Pain often awakes patient’s up at night A change in appetite with weight gain (duodenal)

57 Diagnostic Tests History and Physical (family history) Endoscopy (EGD)
Stool for occult blood H-pylori test (carbon ureas breath test) Gastric secretion studies Biopsy

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59 Medical Management Drug Therapy Diet Therapy Lifestyle Changes
Surgical Intervention

60 Nursing Diagnosis Actual pain Anxiety/Fear
Ineffective individual coping Potential fluid volume deficit Knowledge deficit Disturbed sleep pattern Nutrition deficit

61 Nursing Interventions
Assessment of symptoms and family history Assess for complications Medication and diet education Monitor pain management Monitor nutritional status Encourage smoking and alcohol cessation

62 Complications Gastrointestinal bleeding Gastric Perforation
Pyloric obstruction

63 Treatment of Complications
GI bleed Perforation Pyloric obstruction

64 Surgical Interventions
Vagotomy & Pyloroplasty Gastroenterostomy

65 pyloroplasty

66 Post Operative Management
Assess patient Assess vital signs Monitor gastric decompression and output Monitor labs Monitor continued ileus Monitor for gastric delay emptying and recurrent ulcerations

67 End of Part I Gastrointestinal System The Appendix follows on this Power Point (Medication Information, etc…)

68 Pharmacology: Anti-Acids (Antacids) Prototype: aluminum hydroxide gel ( Amphojel )
Pharmacological Action Neutralize gastric acid and inactivate pepsin. Mucosal protection may occur by the antacid’s ability to stimulate the production of prostaglandins. Therapeutic Uses Treat peptic ulcer disease (PUD) by promoting healing and relieving pain. Symptomatic relief for clients with GERD. Nursing Interventions and Client Education Clients taking tablets should be instructed to chew the tablets thoroughly and then drink at least 8 oz of water or milk. Teach the client to shake liquid formulations to ensure even dispersion of the medication. Compliance is difficult for clients because of the frequency of administration. Administered seven times a day: 1 hr before and 3 hr after meals, and again at bedtime. Teach clients to take all medications at least 1 hr before or after taking an antacid. Evaluation of Medication Effectiveness Depending on therapeutic intent, effectiveness may be evidenced by: Healing of gastric and duodenal ulcers. Reduced frequency or absence of GERD symptoms. No signs or symptoms of GI bleeding. Back to Concept Map

69 Pharmacology: Prokinetic Agents Prototype : metoclopramide ( Reglan )
Pharmacological Action Block dopamine and serotonin receptors in the chemoreceptor trigger zone (CTZ), and thereby suppress emesis. Prokinetic agents augment action of acetylcholine which causes an ↑ in upper GI motility. Therapeutic Uses Control postoperative and chemotherapy-induced nausea and vomiting. Prokinetic agents are used to treat GERD. Prokinetic agents are used to treat diabetic gastroparesis. Side Effects / Adverse Effects Extra Pyramidal Symptoms (EPS) Sedation Diarrhea Contraindications / Precautions Contraindicated in clients with GI perforation, GI bleeding, bowel obstruction, and hemorrhage Contraindicated in clients with a seizure disorder due to ↑ risk of seizures Use cautiously in children and older adults due to the ↑ risk for EPS. Nursing Interventions and Client Education Monitor clients for CNS depression and EPS. Can be given orally or intravenously. If dose is < 10 mg, it may be administered undiluted over 2 min. If the dose is > 10 mg, it should be diluted and infused over 15 min. Dilute medication in at least 50 mL of D5W or lactated Ringer’s solution. Evaluation of Medication Effectiveness Control of nausea and vomiting Back to Concept Map

70 Pharmacology: Histamine 2 (H2) Receptor Agonists Prototype : ranitidine hydrochloride (Zantac)
Pharmacological Action Suppress the secretion of gastric acid by selectively blocking H2 receptors in parietal cells lining the stomach. Therapeutic Uses Gastric and peptic ulcers, gastroesophageal reflux disease (GERD), and hypersecretory conditions, such as Zollinger-Ellison syndrome. Used in conjunction with antibiotics to treat ulcers caused by H. pylori. Therapeutic Nursing Interventions and Client Education Encourage client to avoid aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs). Ranitidine can be taken with or without food. Treatment of peptic ulcer disease is usually started as an oral dose twice a day until he ulcer is healed, followed by a maintenance dose, which is usually taken once a day at bedtime. Evaluation of Medication Effectiveness Depending on therapeutic intent, effectiveness may be evidenced by: Reduced frequency or absence of GERD symptoms (e.g., heartburn, bloating, belching). No signs or symptoms of GI bleeding. Healing of gastric and duodenal ulcers. Back to Concept Map

71 Pharmacology: Proton Pump Inhibitors Prototype : omeprazole (Prilosec)
The client should take omeprazole once a day prior to eating. Encourage the client to avoid irritating medications (e.g., ibuprofen and alcohol). Active ulcers should be treated for 4 to 6 weeks. Pantoprazole (Protonix) can be administered to the client intravenously. Monitor the client’s IV site for signs of inflammation (e.g., redness, swelling, local pain) and change the IV site if indicated. Teach clients to notify the primary care provider for any sign of obvious or occult GI bleeding (e.g., coffee ground emesis). Evaluation of Medication Effectiveness Depending on therapeutic intent, effectiveness may be evidenced by: Healing of gastric and duodenal ulcers. Reduced frequency or absence of GERD symptoms (e.g., heartburn, sour stomach). No signs or symptoms of GI bleeding. Pharmacological Action Reduce gastric acid secretion by irreversibly inhibiting the enzyme that produces gastric acid. Reduce basal and stimulated acid production. Therapeutic Uses Prescribed for gastric and peptic ulcers, GERD, and hypersecretory conditions (e.g., Zollinger-Ellison syndrome). Precaution: Increases the risk for pneumonia. Omeprazole ↓ gastric acid pH, which promotes bacterial colonization of the stomach and the respiratory tract. Use cautiously in clients at high risk for pneumonia (e.g., clients with COPD). Nursing Interventions and Client Education Do not crush, chew, or break sustained-release capsules. The client may sprinkle the contents of the capsule over food to facilitate swallowing. Back to Concept Map

72 Pharmacology: Mucosal Barriers Prototype: sucralfate ( Carafate )
Nursing Interventions and Client Education Assist the client with the medication regimen. Instruct the client that the medication should be taken on an empty stomach. Instruct the client that sucralfate should be taken four times a day, 1 hr before meals, and again at bedtime. The client can break or dissolve the medication in water, but should not crush or chew the tablet. Encourage the client to complete the course of treatment. Evaluation of Medication Effectiveness Depending on therapeutic intent, effectiveness may be evidenced by: Healing of gastric and duodenal ulcers. No signs or symptoms of GI bleeding. Pharmacological Action Changes into a viscous substance that adheres to an ulcer; protects ulcer from further injury by acid and pepsin. Viscous substance adheres to the ulcer for up to 6 hr. Sucralfate has no systemic effects. Therapeutic Uses Acute duodenal ulcers and maintenance therapy. Investigational use in gastric ulcers and gastroesophageal reflux disease. (GERD) Back to Concept Map

73 ***Diagnostic Tests Blood Tests Complete Blood Count (CBC c Diff)
Stool Tests: Stool for occult blood; (Guiac) Stool for ova & parasites (O&P); Stool for Clostridium difficile (C-Diff) Stool Culture & Sensitivity (C&S) Radiology: Upper GI Series (UGI) Upper GI Series with Small Bowel Follow-Through (UGI-SBFT) Barium Enema Endoscopy Endoscopy: Return to Concept Map Clostridium difficile


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