West Coast University BSN Program NURS 120

1. West Coast University BSN Program NURS 120 Medical Surgical Nursing Gastrointestinal System - Gastroesophageal Reflux Disease Gastroenteritis Constipation Hemorrhoids Diarrhea

2. Anatomy of Gastrointestinal system

3. The GI System • Tube approximately 30 feet ( 9 meter) long from mouth to the anus. • Innervated by parasympathetic ( excitatory) and sympathetic nervous system (inhibitory) of the ANS. • Enteric Nervous system – GI tract own nervous system that contains numerous neurons and has the ability to control movement and secretion of the GI tract. • Two types of movements of the GI tract – mixing (segmentation) and propulsion (peristalsis). • Blood Supply- Upper GI receives blood from Splanchnic artery. Blood draining the GI tract empties into the portal vein, then perfuse to liver. Small intestine receives from hepatic and superior mesenteric arteries. Large intestine receives from superior and inferior mesenteric arteries.

4. The GI System • Secretions of GI systems – enzymes, hormones for digestions, mucus to provide protection and lubrication, and water and electrolytes. • Physiology (Functions) - Ingestion and Propulsion of food (Mouth, Pharynx and Esophagus). - Digestion and Absorption (Mouth, Stomach, Small Intestine) - Elimination (Large Intestine)

5. GI System Physiology • Ingestion and Propulsion of food- intake of food. Saliva is use for food lubrication. Mechanical breakdown of food. • Digestion – begins in the mouth, in the stomach the digestion of protein begins with the release of pepsinogen turn to pepsin. -Food stay in the stomach 3-4 hours. - When food enters stomach and small intestine,hormones are release into the bloodstream. - Digestion is complete at the small intestine. Bile is necessarry for digestion of fats. - Cholecystokinin – stimulates pancrease to synthesize and secretes enzymes for digestion of carbohydrates, fats and protein.

6. GI System Physiology • Digestion – Enzyme present at the microvilli completes digestion process. These enzymes hydrolyze disaccharides to monosaccharides and peptides to amino acids for absorption. • Elimination – large intestine is responsible for absorption of water and electrolytes. Large intestine also serve as reservoir for fecal mass until defecation occurs. Defecation is a reflex action involving voluntary and involuntary control. Defecation can be facilitated by Valsalva Maneuver. This maneuver involves contracation of the chest muscles on a close glottis with simultaneous contraction of the abdominal muscle.

7. GI System Physiology • Valsalva Maneuver increases intraabdominal pressure. Maybe contraindicated in a client with head injury, eye surgery, cardiac problems, hemorrhoids, abdominal surgery,or liver cirrhosis. • Constipation – is common in the older adult and is due to many factors including slower peristalsis, inactivity, decreased dietary fibers, decreased fluids, depression, constipating medications, and laxative abuse.

8. GI Secretions Related to Digestion page 929 • Salivary Glands – Salivary amylase, Pepsinogen • Stomach- HCl acid, Lipase, Intrinsic Factor • Small Intestine - Enterokinase, Amylase, Peptidases, Aminopeptidases, Maltase, Sucrase, Lactase, Lipase • Pancrease - Trypsinogen, Chymotrypsin, Amylase, Lipase • Liver and Gallbladder - Bile

9. Factors that affects the GI System Functioning • Main function – supply nutrients to body cells. • Factors outside GI system can influence its functioning e.g. stress and anxiety. • Stress can be experienced as anorexia, epigastric pain and abdominal pain. • Physical factors that affect GI functioning includes dietary intake, ingestion of alcohol and caffeine containing products, cigarette smoking, poor sleep, and fatigue.

10. Gerontologic Considerations : Effects of Aging on the GI System. Expected Aging Changes: Mouth – Gingival Retraction Decreased taste buds Decrease volume of saliva Atrophy of gingival tissue Esophagus – Decreased esophageal sphincter pressure, Motility decreased. Abdominal Wall – Thinner and less taut. Decrease in number and sensitivity of sensory receptors.

11. Gerontologic Considerations : Effects of Aging on the GI System. • Stomach – Atrophy of gastric mucosa, decrease in blood flow. • Small Intestine- Slight decrease in secretion of most digestive enzymes and motility. • Liver – Decrease size and lowered in position. Decrease in protein synthesis, ability to regenerate decreased. • Large Intestine, Anus, Rectum – Decreased anal sphincter tone and nerve supply to rectal area Decrease muscular tone, decreased motility, Increase in transit time, sensation to defecation decreased.

12. Gerontologic Considerations : Effects of Aging on the GI System. • Pancreas – Pancreatic duct distended, lipased production decrease, pacreatic reserve impaired. Differences in Assessment Findings: • Loss of teeth, presence of dentures, diminish sense of taste. • Dry oral mucosa. • Epigastic distress, dysphagia, potential for hiatal hernia and aspiration. • Food intolerances, signs of anemia resulting from cobalaminmalabsorption, decreased gastric emptying. • Complaints of indigestion, slowed intestinal transit.

13. Gerontologic Considerations : Effects of Aging on the GI System. Differences in Assessment Findings: Cont. • Delayed absorption of fat-soluble vitamins. • Liver is easier to palpate due to lower border. • Liver - Decrease in drug metabolism. • Fecal Incontinence • Flatulence, abdominal distention, relaxed perineal musculature, constipation, fecal impaction. • Impaired fat absorption, decreased glucose tolerance.

14. Factors that determine whether GERD is present • Efficiency of antireflux mechanism • Volume of gastric contents • Potency of refluxed material • Effeciency of esophageal clearance • Resistance of the esophageal tissue to injury and the abilityn to repair tissue The client must have several episodes of reflux for GERD to be present.

15. Assessment: Functional health Patterns Table 39-8 • Health perception- health management Patterns: - Nurse should ask about health practices related to GI system e.gmaintenace of normal body weight. • Nutritional Metabolic Patterns: - Dietary history should be taken and compared with the food pyramid. • Elimination Patterns: -Client should be asked on the frequency, time of day, and usual consistency of stool should be noted. • Activity –Exercise Patterns. - The pt. ambulatory status should be checked.

16. Assessment: Functional health Patterns Table 39-8 • Sleep-rest Patterns: - The pt. should be asked if GI symptoms affects sleep or rest. • Cognitive-Perceptual Patterns: - The pt. should be assess with sensory adequacy, change in smell or taste. Pain should also be assessed. • Self-Perception/Self-Concept Pattern: - Assess the pt’s willingness to engage in self-care and to discuss this situation.

17. Assessment:Functional Health Patterns Tbl: 39-8 • Role-Relationship Pattern: - Assess availability of and satisfaction with support. • Sexuality- reproductive Pattern: - Assess for effect of problems related to GI on pt’s sexuality and reproductive status. • Coping-Stress Tolerance Pattern; - Determine what is the stressor for the pt. and what coping mechanisms the pt. uses to function with these stressors. • Value-Belief Pattern: Pt’s spiritual and cultural beliefs regarding food preparation should be assessed.

18. Different Diets for GI System Disorders • Diet for constipation –High Fiber diet e.g. Raw Fruits and Fruit juices esp. prune and grape juice, raw vegetables, cabbage, sweets, alcohol and highly spicy foods stimulates stool production. • Foods that can contribute fecal incontinence e.g. chocolate, coffee, tea, and other caffeinated beverages stimulates the anal sphincters to relax . • Food that can thickened stool e.g. bananas, rice, bread, potatoes, cheese, yogurt, oatmeal, oatbran, boiled milk and pasta.

19. Different Diets for GI System Disorders • Odor-causing foods include cabbage family vegetables, beans, garlic, eggs, fish, and turnips. • Gas –producing foods include beans, beer, carbonated beverages, cucumbers, cabbage, broccoli, dairy products and corn. • Ileostomy diet – avoid excess gas, maintain a soft stool, and avoid obstruction of the catheter. Pt should avoid: coffee, alcohol, and gas forming foods, skins, seeds and nuts including corn, olives and peas, pineapple, berries, fresh fruits, milk products is cause excessive gas.

20. Different Diets for GI System Disorders • Diet for Peptic Ulcer – permit the client almost any foods that do not produce discomfort. - Avoid foods that stimulate acid secretions but do not neutralize acids. - Foods include coffee, tea, meat broth, and alcohol. • Lactose Intolerance – Avoid milk and milk products. Use soymilk products. - Restricting milk may result in Calcium , riboflavin and Vit. D deficiency. • Gluten-Free Diet - diet completely free of ingredients derived from gluten-containing cereals/ wheat, barley, rye, Malts , as well as the use of gluten as a food additive in the form of a flavoring, stabilizing or thickening agent. It is the only medically accepted treatment for celiac disease and wheat allergy.

21. Different Diets for GI System Disorders • Low residue diet is a special diet, which is low in fiber and high in other dietary elements. • The low residue diet is used as a preparation for certain medical examinations as well as an aid to cure certain health problems. The low residual diet is thus prescribed under certain special conditions only. • The low residue diet contains less than 10-15 grams of fiber per day.What does the low residue diet aim at?Basically, by lowering the dietary fiber contents, the low residue diet is designed to reduce the frequency and volume of the stools. The low residue diet helps to prolong the intestinal transit time. Simply, the low residue diet aims to reduce the bowel activity.

22. Gastrointestinal Disorders • GERD • PUD • Gastroenteritis • Constipation • Diarrhea • Inflammatory Bowel Diseases • Colorectal Cancer • Hemorrhoids

23. Gastroesophageal Reflux Disease (GERD) • GERD– results of an incompetent lower esophageal sphincter that allows regurgitation of acidic gastric contents into the esophagus. • Condition characterized by gastric contents and enzyme leakage into esophagus. • Corrosive fluids (stomach acid)irritate the esophageal tissue and limit its ability to clear the esophagus. • Causes prolonged or frequent transiet relaxation of the lower esophageal sphincter (LES) at the base of the esophagus, or delayed gastric emptying.

24. Symptoms of GERD • Frequent and prolonged retrosternal heartburn (dyspepsia) and regurgitation (acid reflux) in relation to eating or activities. • Chronic cough • Dysphagia • Belching ( eructation) • Flatulence (gas) • Atypical chest pain • Asthma exacerbation.

25. GERD

26. Nursing Assessment of GERD • Heartburn after eating • Feeling of fullness and discomfort after eating • Positive diagnosis determined by fluoroscopy or Barium Swallow. Fluoroscopy is a type of medical imaging that shows a continuous x-ray image on a monitor, much like an x- ray movie. It is used to diagnose or treat patients by displaying the movement of a body part or of an instrument or dye (contrast agent) through the body. During a fluoroscopy procedure, an x-ray beam is passed through the body. The image is transmitted to a monitor so that the body part and its motion can be seen in detail.

27. Etiology (Cause) of GERD • Any factor that relaxes the LES such as: SMOKING CAFFEINE ALCOHOL DRUGS • Any factor that increases the abdominal pressure: OBESITY TIGHT CLOTHING AT THE WAIST ASCITES PREGNANCY • OLDER AGE and/or debilitating condition that weakens the LES tone.

28. Contributing Factor • Diet: Excessive ingestion of foods that relaxes the LES. - Fatty and fried foods - Chocolate - Caffeinated beverages such as coffee - Peppermint - Spicy foods - Tomatoes - Citrus foods - Alcohol

29. Contributing Factors • Distended abdomen from overeating or delayed emptying. • Increased abdominal pressure e.g. ascites, obesity, pregnancy, bending at the waist, tight clothing at the waist. • DRUGS that relaxes the LES e.g. Theophylline, Nitrates, Calcium Channel Blockers, anticholenergics, and Diazepam. • Drugs such as NSAIDS, or events like stress that increase gastric acid.

30. Contributing Factors • Debilitation or age related conditions resulting in weakened LES tone. • Hiatal Hernia – herniation of the esophagogastric junction and the portion of the stomach into the chest through the esophageal hiatus of the diaphragm. Hiatal Hernia –LES displacement into the thorax with delayed esophageal clearance. • Lying flat

31. Diagnostic Procedures for GERD and Nsg. Interventions • Hx : Symptoms 4 to 5 times per week on a consistent basis • Improvement after a 6 week-course of Proton pump inhibitors (PPI) main action is a pronounced and long-lasting reduction of gastric acid production e.g. Omeprazole (Prilosec) , Lansoprazole (Prevacid), Pantoprazole (Protonix). • Barium Upper GI : Pre-Procedure:Fiber diet for 2-3 days before the barium swallow test. You will be asked not to eat or smoke after midnight before the exam. Post procedure: assess for BS and potential constipation. • Endoscopy – pt. under conscious sedation to observe for tissue damage. • Esophageal Manometry – used to measure muscle tone of LES and pH monitoring.

32. Esophageal Manometry • The exam is often done before and after medical or surgical treatment of the esophagus. Esophageal manometry is very effective in evaluating the contraction function of the esophagus in many situations. • Manometry is the recording of muscle pressures within an organ. So esophageal manometry measures the pressure within the esophagus. It can evaluate the action of the stripping muscle waves in the main portion of the esophagus as well as the muscle valve at the end of it.

33. Therapeutic Interventions • Surgery (Fundoplication) - surgeon wraps the fundus of the stomach around and behind the esophagus through laparoscopy to create a physical barrier. Nursing Interventions • Assessments -Monitor for sign and symptoms – classic sign: Dyspepsia especially after eating. chronic cough from irritation, hypersalivation, eructation, flatulence, , atypical chest pain,

34. Assessment • Assess client’s dietary intake pattern. Attention to food containing caffeine and fat. • Smoking history. • Alcohol use. • Weight NANDA Nursing Diagnosis • Acute pain • Deficient knowledge • Anxiety

35. Nursing Plans and Interventions • Determine eating patterns that alleviates symptoms: • Encourage small frequent meals. • Encourage elimination of foods that are determined to aggravate symptoms. • Encourage client to sit up while eating and remain in an upright position for at least an hour after eating. A fowler or semi-fowler position is beneficial in reducing the amount of regurgitation as well as in preventing the encroachment of the stomach upward through the opening of the diaphragm. 4. Encourage client to stop eating three hours before bedtime. 5. Teach about commonly prescribed medications ( H2 antagonist, antacids).

36. Teaching Plans for client and family • Differentiate between the symptoms of hiatal hernia and those of MI. • Alert to the possibility of aspirations. • Diet – avoid offending foods avoid large meals remain upright after eating avoid eating before going to bed. • Lifestyle – avoid tight fitting clothing Lose weight if applicable. Elevate the head of the bed with blocks. Use of pillow is not recommended as this rounds the back, bringing the stomach contents up closer to the chest.

37. Medications • Antacids – e.g. Mylanta Neutralize excess acids. administer 1-3 hours after eating and at HS. Should be separated with other meds at least 1 hour. • Histamine 2 receptor antagonist – e.g. Zantac (Ranitidine). Reduce the secretion of acid. • Proton Pump Inhibitors (PPIs) – e.gProtonix (Pantoprazole). • Reglan (Metochlopramide HCL) to increase motility of the esophagus and stomach.

38. Complications • Aspiration • Asthma exacerbation • Frequent URI, sinus or ear infections. • Aspiration pneumonia • Esophageal stricture (scarring) • Erosive esophagitis (ulceration and hemorrage). • Barrett’s epithelium (premalignant) and esophageal carcinoma.

39. Peptic Ulcer Disease • Ulceration that penetrates the mucosal wall of the GI tract. • Gastric Ulcer- occurs in the lessaer curvature of the GI tract. • Doudenal Ulcer – occurs in the doudenum • Esophageal Ulcers – occurs in the esophagus

40. Peptic Ulcer Disease

41. Cause of PUD • Peptic Ulcer – some causes are unknown. • Gastric Ulcers – significant numbers are caused by Helicobacter Pylori (H. Pylori). Risk Factors in the Development of PUD: • Drugs ( NSAIDS, Corticosteroids) • Alcohol • Cigarette Smoking • Acute medical Crisis or trauma (Stress)

42. Symptoms Common to all types of Ulcers • Belching • Bloating • Epigastric pain radiating to the back (not associated with the type of food eaten) and relieved by antacid Nursing Assessment: • Determine how food intake affects pain. • Take Hx of antacid or histamine antagonist use. • Determine presence of melena (blood in the stool). • Determine presence and location of peptic ulcer.

43. Diagnostic Test • Barium Swallow • Upper endoscopy • Gastric Analysis -indicating increased levels of stomach acid. Potential Complications • Hemorrhage • Perforation ( which always require surgery) • Obstruction

44. NANDA Nursing Diagnosis • Pain related to … • Imbalance Nutrition: Less than body requirements • Deficient knowledge deficit • Risk for injury NURSING PLANS and INTERVENTIONS • Determine symptom onset and how symptoms are relieved. • Monitor color, quantity, consistency of stools and emesis. Test for occult blood.

45. Nursing Plans and Interventions cont: • Administer medications as prescribed. - Antacids (Maalox): Need to take several times a day. Administer after meals Assess Hx of renal disease for Mg products. Electrolyte adjustment can result in renal insufficiency and calcinosis. - H2 receptor Antagonist – Cigarette smoking can interferes with drug action. Expensive.

46. Nursing Interventions PUD Medications: • Mucosal healing agent (Sucralfate) – to be taken at leats 1 hour prior to meals. Antacids interfere with absorption. • PPI s - Taken before meals Do not crush or chew IV Pantoprazole to be given over 3 min period. Inhibit absorption of other drug Resume oral therapy as soon as feasible. • Antiemetics • Cough suppressants • Stool Softeners

47. Nursing Management cont” • Administer mucosal healing agent as prescribed. • Encourage small , frequent meals, no bedtime snack and avoid beverages containing caffeine. • Prepare for surgery for uncontrolled bleeding, obstruction, or perforation occurs. - Gastric resection - Vagotomy - Pyloroplasty • Teach client that DUMPING SYNDROME may occur postoperatively.

48. Dumping Syndrome • Secondary to rapid entry of hypertonic food into jejunum (pull water out of bloodstream) • Occurs 5-30 min after eating. • Characterized by vertigo, syncope, sweating, pallor, tachycardia. • Minimized by small frequent meals, high protein, high fat, low carb diet. • Exacerbate by consuming liquids with meals. Helped by lying down after eating.

49. PUD Nursing Management cont. • Teach client to avoid medications that increase risk for developing peptic ulcer. - Salicylates - NSAIDS e.g. Ibuprofen - Corticosteroid in high dosage - Reserpine (antihypertensive) - Anticoagulants • Teach client lifestyle modification: - Cessation of smoking and stress management. • Teach client of symptoms of GI bleeding. - Dark tarry stools - coffee ground emesis - bright red rectal bleeding - Fatigue - Pallor - Severe abdominal pain ( report immediately) could denote perforation.

50. Gastroenteritis • Definition - Gastroenteritis is a condition that causes irritation and inflammation of the stomach and intestines (the gastrointestinal tract). Diarrhea, crampy abdominal pain, nausea, and vomiting are the most common symptoms. • Causes: - Viral infection - Bacterial infection (Salmonella) - Parasites - Food-borne illness (such as shellfish) can be the offending agent.