GIT PROBLEMS

REVIEW OF THE
DIGESTIVE
SYSTEM

NCM 102- C
• The Digestive Process
• INGESTION
• MASTICATION
• DEGLUTITION
• DIGESTION
• ABSORPTION
• DEFECATION / EGESTION
• The Digestive Organs
•  SOLID ORGANS
• Liver and gall bladder
• Pancreas
•  THE DIGESTIVE TRACT
• Oral cavity
• Pharynx
• Esophagus
• Stomach
• Small intestines (duodenum, jejunum, ileum)
• The Digestive Organs
•  SOLID ORGANS
• Liver and gall bladder
• Pancreas
•  THE DIGESTIVE TRACT
• Oral cavity
• Pharynx
• Esophagus
• Stomach
• Small intestines (duodenum, jejunum, ileum)
• The Digestive Organs
•  THE DIGESTIVE TRACT (Cont’d)
• Large intestines (cecum, ascending colon,
• hepatic flexure, transverse colon, splenic
• flexure, descending colon, sigmoid colon)
• Rectum
• Anus
The Digestive Organs
• The Oral Cavity
•  The lips and cheeks are involved in facial
• expression, mastication and speech.
•  The tongue is involved in speech, taste,
• mastication, and swallowing.
•  There are 32 permanent teeth, including
• incisors, canines, premolars, and molars. Each
• tooth consists of a crown, neck and root.
•  The roof of the oral cavity is divided into the
• hard and soft palates.
• The Oral Cavity
•  The salivary glands produce serous and
mucous
• secretions. The three pairs of salivary glands
• are: parotid, submandibular, and sublingual
• glands.
• The Pharynx and Esophagus
•  The pharynx consists of the nasopharynx,
• oropharynx and laryngopharynx.
•  The esophagus connects the pharynx to the
• stomach. The upper and lower esophageal
• sphincters regulate movement.
The Upper Digestive Tract
• The Stomach
•  There are cardiac (to the esophagus) and pyloric
• (to the duodenum) openings in the stomach.
•  The walls of the stomach consists of three
• muscle layers, longitudinal, circular, and
• oblique.
•  Gastric glands produce mucus, hydrochloric
• acid, pepsin and gastrin.
•  Gastric cells:
• Surface mucous cells (mucus)
• Mucous neck cells (mucus)
• The Stomach
•  Gastric cells (Cont’d):
• Parietal cells (hydrochloric acid and
• intrinsic factor)
• Endocrine cells (regulatory hormones)
• Chief cells (pepsinogen)
The Stomach
• The Small Intestines
•  The small intestine is divided into the
• duodenum, jejunum, and ileum.
•  Circular folds, villi, and microvilli greatly
• increase the surface area of the intestinal
lining.
•  Duodenal glands produce mucus.
The Small Intestines
• The Large Intestines
•  The cecum forms a blind sac at the junction of
• the small and large intestines. The appendix is
• a blind sac off the cecum.
•  The colon consists of ascending, transverse,
• descending, and sigmoid portions.
•  Smooth muscles of the large intestine wall are
• arranged into bands called teniae coli that
• contract to produce pouches called haustrae.
•  The large intestine contains mucus-producing
• crypts.
The Large Intestines
• The Rectum and Anus
•  The rectum is a straight tube that ends at
the
• anus.
•  The anal canal is surrounded by an internal
anal
• sphincter (smooth muscle) and an external
anal
• sphincter (skeletal muscle).
• The Digestive Process
•  Amylase in saliva starts starch digestion.
• Mucin provides lubrication.
•  Mastication is accomplished by the teeth which
• cut, tear and crush the food.
•  During the voluntary phase of deglutition, a
• bolus of food is moved by the tongue from the
• oral cavity to the pharynx.
•  During the pharyngeal phase of deglutition, the
• soft palate closes the nasopharynx, and the
• epiglottis closes the opening into the larynx.
• Pharyngeal muscles move the bolus to the
• esophagus.
 NURSING
MANAGEMENT OF
GIT PROBLEMS
ASSESSMENT
• Health History and Clinical
• Manifestations
•  Complete history, focusing on symptoms
• common to GI dysfunction.
•  Information about any previous GI disease is
• important.
•  Past and current medication use and any previous
• treatment or surgery.
•  Dietary history.
•  Use of alcohol and tobacco including type and
• amount.
•  Appetite and eating patterns.
• Health History and Clinical
• Manifestations
•  Unexplained weight gain and loss over the
past
• year.
•  Stool characteristics.
•  Psychosocial, spiritual, or cultural factors
that
• may be affecting the patient.
• Pain
•  Major symptom of GI disease.
•  Character
•  Duration
•  Pattern
•  Frequency
•  Location
•  Distribution of referred pain
•  Time of the pain
• Indigestion
•  Upper abdominal discomfort or distress
• associated with eating.
•  Most common symptom of patients with GI
• dysfunction.
•  Fatty foods tend to cause the most
discomfort.
•  Coarse vegetables and highly seasoned
foods can
• also cause considerable distress.
• Intestinal Gas
•  The accumulation of gas in the GIT may
result in
• belching or flatulence.
•  Patients often complain of bloating,
distention, or
• “being full of gas.”
• Nausea and Vomiting
•  Vomiting is usually preceded by nausea,
which
• can be triggered by odors, activity, or food
• intake.
•  Emesis, or vomitus, may vary in color and
• content.
•  Hematemesis refers to bloody vomitus.
• Change in Bowel Habits and
• Stool Characteristics
•  These may signal colon disease.
•  Diarrhea (abnormal increase in the frequency and
• liquidity of the stool or in daily stool weight or
• volume) occurs when the contents move so
• rapidly through the intestine and colon.
•  Constipation (decrease in the frequency of stool,
• or stools that are hard, dry, and of smaller volume
• than normal) may be associated with anal
• discomfort and rectal bleeding.
• Change in Bowel Habits and
• Stool Characteristics
•  Stool is normally light to dark brown.
•  Ingestion of certain foods and medications, as
• well as the presence of blood, can change the
• appearance of stool.
•  Bulky, greasy, foamy stools that are foul in odor;
• stool color is gray with a silvery sheen (fat
• malabsorption).
•  Light gray or clay-colored stool (absence of
• urobilin).
•  Mucus threads or pus in stools (infection).
• Change in Bowel Habits and
• Stool Characteristics
•  Scybala (small, dry, rock-hard masses) often
seen
• in narrowing of the colonic lumen.
•  Loose, watery stool that may or may not be
• streaked with blood (inflammatory
conditions).
• PHYSICAL ASSESSMENT
•  Assessment of the mouth, abdomen and
rectum.
•  Mouth, tongue, buccal mucosa, teeth and
gums
• are inspected, and ulcers, nodules, swelling,
• discoloration, and inflammation are noted.
•  Patients with dentures should remove them
• during this part of the examination to allow good
• visualization.
• PHYSICAL ASSESSMENT:
• The Abdomen
•  Patient lies supine with knees flexed slightly for
• inspection, auscultation, palpation and
• percussion.
•  The nurse performs inspection first, noting skin
• changes and scars from previous surgery.
•  It is also important to note the contour and
• symmetry of the abdomen, to identify any
• localized bulging, distention, or peristaltic waves.
• Abdominal Assessment:
• Auscultation
•  Character, location and frequency of bowel
• sounds.
•  Assess bowel sounds in all four quadrants using
• the diaphragm of the stethoscope.
•  Categorize and document frequency of bowel
• sounds into normal (5 to 6/min), hypoactive (1
• sound/min), hyperactive (5 to 6 sounds in less
• than 30 seconds), or absent (no sound in 3 to 5
• minutes).
• Abdominal Assessment:
• Percussion and Palpation
•  Tympany or dullness.
•  Light palpation for identifying areas of
• tenderness or swelling.
•  Deep palpation to identify masses in all four
• quadrants.
•  If any area of discomfort is identified, the
nurse
• can assess for rebound tenderness.
• Anal and Perineal Areas
•  Inspect and palpate areas of excoriation or
rash,
• fissures or fistula openings, or external
• hemorrhoids.
•  A digital rectal examination can be
performed to
• note any area of tenderness or mass.
• DIAGNOSTIC EVALUATION
•  Blood tests are ordered initially:
• complete blood count
• carcinoembryonic antigen (CEA)
• liver function tests (AST, ALT, alkaline
• phosphatase, bilirubins)
• serum cholesterol
• triglycerides
• DIAGNOSTIC EVALUATION:
• Stool Tests
•  Inspecting the specimen for consistency and
• color and testing for occult blood.
•  Special tests for fecal urobilinogen, fat, nitrogen,
• parasites, pathogens, food residues.
•  Stool samples are usually collected on a random
• basis unless a quantitative study (e.g., fecal fat,
• urobilinogen) is to be performed.
•  Random samples should be sent promptly to the
• laboratory, or should be refrigerated until they
• are taken to the laboratory.
• DIAGNOSTIC EVALUATION:
• Stool Tests
•  Fecal occult blood is useful in initial screening
• for several disorders.
•  False-positive test results may occur if the patient
• has eaten raw meat, liver, poultry, turnips,
• broccoli, cauliflower, melons, salmon, sardines,
• or horseradish within 3 days before testing.
•  Medications that can cause gastric irritation
• (aspirin, ibuprofen, indomethacin, colchicine,
• corticosteroids, cancer chemotherapeutic agents
• and anticoagulants) may also cause false-positive
• results.
• DIAGNOSTIC EVALUATION:
• Abdominal Ultrasonography
•  Noninvasive diagnostic technique in which
highfrequency
• sound waves are passed into internal
• body structures and the ultrasonic echoes are
• recorded on an oscilloscope as they strike tissues
• of different densities.
•  Requires no ionizing radiation, no noticeable side
• effects, and is relatively inexpensive.
•  Cannot be used to examine structures that lie
• behind bony tissue.
• DIAGNOSTIC EVALUATION:
• Abdominal Ultrasonography
•  Patient fasts for 8 to12 hours before the test
to
• decrease the amount of gas in the bowel.
•  Fat-free meal if gallbladder studies are being
• performed.
•  Abdominal ultrasonography should always
be
• performed before a barium study.
• DIAGNOSTIC EVALUATION:
• Radiologic Imaging
•  X-rays can delineate the entire GI tract after the
• introduction of a contrast agent.
•  The Upper GI series enables the examiner to
• detect or exclude anatomic or functional
• derangement of the upper GI organs or
• sphincters, and aids in the diagnosis of ulcers,
• varices, tumors, regional enteritis and
• malabsorption syndromes.
• DIAGNOSTIC EVALUATION:
• UGIS
•  The patient may need to maintain a low-residue
• diet for several days before the test.
•  NPO after midnight before the test.
•  Laxatives may be prescribed to clean out the
• intestinal tract.
•  No smoking (smoking stimulates gastric
• motility).
•  Follow-up care: increased fluid intake, stool
• monitoring until they return to normal color, use
• of laxatives or performance of an enema.
DIAGNOSTIC EVALUATION:
UGIS
• DIAGNOSTIC EVALUATION:
• UGIS
•  The patient may need to maintain a low-residue
• diet for several days before the test.
•  NPO after midnight before the test.
•  Laxatives may be prescribed to clean out the
• intestinal tract.
•  No smoking (smoking stimulates gastric
• motility).
•  Follow-up care: increased fluid intake, stool
• monitoring until they return to normal color, use
• of laxatives or performance of an enema.
• DIAGNOSTIC EVALUATION:
• LGIS
•  Preparation: emptying and cleansing the lower
• bowel.
•  Low-residue diet 1 to 2 days before the test.
•  Clear liquid diet and a laxative the evening
• before the test.
•  Nothing by mouth after midnight.
•  Cleansing enema until with clear return flow the
• following morning before the test.
•  Enemas are contraindicated in patients with
• active inflammatory disease of the bowel.
• DIAGNOSTIC EVALUATION:
• LGIS
•  Active GI bleeding also may prohibit the use
of
• laxatives and enemas.
•  Follow-up care: enema or laxative to ensure
• barium removal, increasing fluid intake, stool
• monitoring until barium has been totally
• eliminated.
DIAGNOSTIC EVALUATION:
LGIS
• DIAGNOSTIC EVALUATION:
• Computed Tomography
•  Provides cross-sectional images of abdominal
• organs and structures.
•  The patient should not eat or drink for 8 hours
• before the test.
•  The practitioner may prescribe an intravenous or
• oral contrast agent.
•  Obtain a history and ask about allergies.
•  Should be performed before barium studies.
DIAGNOSTIC EVALUATION:
Computed Tomography
• ENDOSCOPIC PROCEDURES
•  Fibroscopy
•  Esophagogastroduodenoscopy (EGD)
•  Anoscopy
•  Proctoscopy
•  Sigmoidoscopy
•  Colonoscopy
•  Small bowel enteroscopy
•  Endoscopy through ostomy
• ENDOSCOPIC PROCEDURES
• EGD
•  Fibroscopes are flexible scopes equipped with
• fiberoptic lenses.
•  Allows direct visualization of the esophageal,
• gastric, and duodenal mucosa through a lighted
• endoscope.
•  Valuable when esophageal, gastric or duodenal
• abnormalities, or inflammatory, neoplastic, or
• infectious processes are suspected.
• ENDOSCOPIC PROCEDURES
• EGD
•  After the patient is sedated, the endoscope is
• lubricated with a water-soluble lubricant and
• passed smoothly and slowly along the back of the
• mouth and down into the esophagus.
•  Biopsy forceps to obtain tissue specimens or
• cytology brushes to obtain cells for microscopic
• study can be passed through the scope.
•  Patients may experience nausea, choking or
• gagging.
• ENDOSCOPIC PROCEDURES
• EGD
•  Use of oral anesthetics and moderate sedation
• makes it important to monitor and maintain the
• oral airway during the after the procedure.
•  Monitor oxygen saturation by means of pulse
• oximeters, and supplemental oxygen may be
• administered if necessary
ENDOSCOPIC PROCEDURES
EGD
• ENDOSCOPIC PROCEDURES
• EGD: Nursing Interventions
•  The patient should not eat or drink for 8 hours
• before the examination.
•  Help the patient spray or gargle with a local
• anesthetic.
•  Administer a sedative such as midazolam
• intravenously just before the scope is introduced.
•  The nurse may also administer atropine to
• decrease secretion, and glucagon to relax smooth
• muscle.
• ENDOSCOPIC PROCEDURES
• EGD: Nursing Interventions
•  Position the patient on the left side to facilitate
• saliva drainage and provide easy access for the
• endoscope.
•  Instruct the patient not to eat or drink until the
• gag reflex returns.
•  Place the patient in the Simms position until he
or
• she is awake, and then place the patient in the
• semi-Fowler’s position until ready for discharge.
• ENDOSCOPIC PROCEDURES
• EGD: Nursing Interventions
•  After gastroscopy, observe for signs of
• perforation: bleeding, unusual dysphagia, fever.
•  Monitor the pulse and blood pressure for
changes
• that can occur with sedation.
•  Test the gag reflex.
•  Relieve minor throat discomfort by giving
• lozenges, saline gargle and oral analgesics.
ENDOSCOPIC PROCEDURES
EGD: Nursing Interventions
• Anoscopy, Proctoscopy and
• Sigmoidoscopy
•  Visualize the lower portion of the colon to
• evaluate rectal bleeding, acute or chronic
• diarrhea, or change in bowel patterns, and to
• observe for ulceration, fissures, abscesses,
• tumors, polyps, or other pathologic processes.
•  Rigid or flexible fiberoptic scopes can be used.
•  Anoscopes are rigid scopes that are used to
• examine the anus and lower rectum.
•  Proctoscopes and sigmoidoscopes are rigid
• scopes used to inspect the rectum and sigmoid
• colon.
• Anoscopy, Proctoscopy and
• Sigmoidoscopy
•  For rigid scopes, the patient assumes the
kneechest
• position at the edge of the bed or examining
• table.
•  Keep the patient informed about the progress of
• the examination and to explain that the pressure
• exerted by the instrument will create the urge to
• have bowel movement.
• Anoscopy, Proctoscopy and
• Sigmoidoscopy
•  For flexible scope procedures, the patient
• assumes a comfortable position on the left side,
• with the right leg bent and placed amteriorly.
•  It is important to keep the patient informed
• throughout the examination and to explain the
• sensations associated with the examination.
•  These examinations require only limited bowel
• preparation, including a warm tap water or
• Fleet’s enema until returns are clear.
• Anoscopy, Proctoscopy and
• Sigmoidoscopy
•  Dietary restrictions usually are not necessary, and
• sedation usually is not required.
•  Monitor the vital signs, skin color and
• temperature, pain tolerance and vagal response
• during the procedure.
•  After the procedure, the nurse monitors the
• patient for rectal bleeding and signs of intestinal
• perforation.
•  On completion of the examination, the patient
• can resume regular activities and dietary
• practices.
• Fiberoptic Colonoscopy
•  Direct visual inspection of the colon to the
• cecum.
•  Used commonly as a diagnostic and screening
• device.
•  Tissue biopsies can be obtained as needed,
and
• polyps can be removed and evaluated.
•  May also be used to evaluate diarrhea of
• unknown cause, occult bleeding, or anemia.
• Fiberoptic Colonoscopy
•  Usually performed while the patient is lying on
• the left side with the legs drawn up toward the
• chest.
•  Discomfort may result from instillation of air to
• expand the colon or from insertion and moving of
• the scope.
•  Potential complications include cardiac
• dysrhythmias and respiratory depression
• resulting from the medications administered,
• vasovagal reactions and circulatory overload or
• hypotension as a result of under- or over
• hydration.
Fiberoptic Colonoscopy
Fiberoptic Colonoscopy
• Fiberoptic Colonoscopy
•  Adequate colon cleansing provides optimal
• visualization and decreases the time needed for
• the procedure.
•  Low residue diet for 2 days prior to the
• examination.
•  Prescribe laxatives for two nights before the
• examination and a Fleet’s or saline enema until
• the return runs clear on the morning of the test.
•  Clear liquid diet starting at noon the day before
• the procedure.
• Fiberoptic Colonoscopy
•  Patient ingests lavage solutions orally at intervals
• over 3 to 4 hours.
•  Cardiopulmonary clearance prior to test for
• patients with known or suspected cardiac and
• pulmonary conditions, and in patients over the
• age of 40 years.
•  NSAIDs, aspirin, ticlopidine and pentoxifylline
• must be discontinued before the test and for 2
• weeks after the procedure.
•  Informed consent must be obtained.
• Fiberoptic Colonoscopy
•  NPO after midnight before the test.
•  Monitor for changes in oxygen saturation, vital
• signs, color and temperature of the skin, level of
• consciousness, abdominal distention, vagal
• response and pain intensity during the test.
•  After the procedure, patients who were sedated
• are maintained on bed rest until fully alert.
•  Abdominal cramps are common as a result of
• increased peristalsis stimulated by air insufflated
• into the bowel during the procedure.
• Fiberoptic Colonoscopy
•  Immediately after the procedure, observe the
• patient for signs and symptoms of bowel
• perforation.
•  If midazolam was used, the nurse should explain
• its amnesic effect; it is important to provide
• written instructions, because the patient may be
• unable to recall verbal information.
•  Instruct the patient to report any bleeding to the
• physician.
NURSING MANAGEMENT OF
GIT PROBLEMS

• ESOPHAGEAL
• DISORDERS