Chapter 38

1. Chapter 38 Digestive Tract Disorders

2. Learning Objectives • Identify the nursing responsibilities in the care of patients undergoing diagnostic tests and procedures for disorders of the digestive tract. • List the data to be included in the nursing assessment of the patient with a digestive disorder. • Describe the nursing care of patients with gastrointestinal intubation and decompression, tube feedings, total parenteral nutrition, digestive tract surgery, and drug therapy for digestive disorders. • Describe the pathophysiology, signs and symptoms, complications, and medical treatment of selected digestive disorders. • Assist in developing nursing care plans for patients receiving treatment for digestive disorders.

3. Anatomy and Physiology of the Digestive Tract Mouth Where teeth, tongue, and salivary glands begin food digestion Pharynx Muscular structure shared by the digestive and respiratory tracts It joins the mouth and nasal passages to the esophagus Esophagus Long muscular tube that passes through the diaphragm into the stomach Stomach Churns and mixes food with gastric secretions until a semiliquid mass called chyme

4. Anatomy and Physiology of the Digestive Tract Small intestine Chemical digestion and absorption of nutrients take place Approximately 20 feet long and consists of three sections: the duodenum, the jejunum, and the ileum Liver and pancreatic secretions enter the digestive tract in the duodenum

5. Anatomy and Physiology of the Digestive Tract Large intestine and anus The first section of the large intestine is the cecum Ascending colongoes up right side of the abdomen Transverse colon crosses abdomen just below waist Descending colon goes down left side of abdomen The last 6 to 8 inches of the large intestine is the rectum, which ends at the anus, where wastes leave the body

6. Figure 38-1

7. Age-Related Changes Teeth are mechanically worn down with age The jaw may be affected by osteoarthritis A significant loss of taste buds with age Xerostomia (dry mouth) is common Walls of esophagus and stomach thin with aging, and secretions lessen Production of hydrochloric acid and digestive enzymes decreases Gastric motor activity slows Movement of contents through the colon is slower Anal sphincter tone and strength decrease

8. Health History Chief complaint and history of present illness A detailed description of the present illness Complaints include weight changes, problems with food ingestion, symptoms of digestive disturbances, or changes in bowel elimination

9. Health History Past medical history Recent surgery, trauma, burns, or infections Serious illnesses, such as diabetes, hepatitis, anemia, peptic ulcers, gallbladder disease, and cancer Alternative methods of feeding or fecal diversion Prescription and over-the-counter medications Food allergy or intolerance

10. Health History Review of systems Description of the patient’s general health state Changes in skin: dryness, bruising, and pruritus Whether the patient has any mouth problems Document if the patient has dentures, partial plates, or natural teeth, and record the last dental examination Problems with chewing or swallowing Changes in appetite, food intake, and weight Nausea, vomiting, dyspepsia, heartburn, flatus, abdominal distention, or pain Assessment of elimination

11. Health History Functional assessment Information about general dietary habits should include the daily pattern of food intake Attitudes and beliefs about food, and changes in dietary habits related to health problems Effects of chief complaint on usual functioning Note whether the patient is able to obtain and prepare food, and eat independently

12. Physical Examination Head and neck Inspect the mouth Abdomen Inspection Auscultation Percussion Palpation Rectum and anus Palpate for lumps and tenderness in the rectum

13. Figure 38-2

14. Diagnostic Tests and Procedures Radiographic studies Upper gastrointestinal (UGI or GI) series Small bowel series Barium enema examination

15. Diagnostic Tests and Procedures Endoscopic examinations Upper GI Esophagoscopy, gastroscopy, gastroduodenoscopy, esophagogastroduodenoscopy, endoscopic retrograde cholangiography Lower GI Colonoscopy, proctoscopy, and sigmoidoscopy

16. Diagnostic Tests and Procedures Laboratory studies Gastric analysis Occult blood test Stool examination

17. Figure 38-3

18. Figure 38-4

19. Therapeutic Measures

20. Gastrointestinal Intubation Tube feedings Delivered by gravity flow or by infusion pump Gastrointestinal decompression For the relief or prevention of distention Levin and gastric sump tubes

21. Total Parenteral Nutrition Bypasses digestive tract by delivering nutrients directly to the bloodstream

22. Figure 38-5

23. Figure 38-6

24. Figure 38-7

25. Figure 38-9

26. Gastrointestinal Surgery Preoperative nursing care The digestive tract is usually cleansed Magnesium citrate or large-volume cathartic (laxative) solutions; enemas Diet limited to liquids 24 hours before surgery Intravenous fluids Oral antibiotics Nasogastric tube inserted and attached to suction

27. Gastrointestinal Surgery Postoperative nursing care Be sure gastrointestinal suction is draining Inspect, describe, and measure the drainage Abdomen for distention and bowel sounds Administer intravenous fluids Keep strict intake and output records Drug therapy Emetics, antiemetics, laxatives, cathartics, antidiarrheals, antacids, anticholinergics, mucosal barriers, histamine-2 (H2)-receptor blockers, prostaglandins, and antibiotics

28. Disorders of the Digestive Tract

29. Anorexia Causes Nausea, decreased sense of taste or smell, mouth disorders, and medications Emotional problems such as anxiety, depression, or disturbing thoughts

30. Anorexia Medical diagnosis Physician assesses for malnutrition Weight may be monitored over several weeks Complete history and physical examination Serum hemoglobin, iron, total iron-binding capacity, transferrin, calcium, folate, B12, zinc Thyroid function tests

31. Anorexia Medical treatment Correctable causes of anorexia are treated, but sometimes no physical cause is found Nutritional supplements

32. Anorexia Assessment Record chronic and recent illnesses, hospitalizations, medications, and allergies Female patient’s obstetric history Symptoms: pain, nausea, dyspnea, extreme fatigue The functional assessment reveals patterns of activity and rest, usual dietary patterns, current stressors, and coping strategies—all can affect appetite

33. Anorexia Interventions Assist with oral hygiene before and after meals Teach proper oral hygiene; refer for dental care Relieve nausea before presenting a meal tray Before serving meal tray, remove bedpans/emesis basins from sight, conceal drains and drainage collection devices, deodorize room if necessary Socialization during mealtime Respect food likes and dislikes Position patient comfortably with easy access to food

34. Feeding Problems Patients with paralysis, arthritis, neuromuscular disorders, confusion, weakness, or visual impairment are likely to need assistance Medical diagnosis and treatment Identifying problems, prescribing treatment Patients often referred to physical therapy and occupational therapy

35. Feeding Problems Assessment Assess each patient’s ability to feed self Determine nature of patient’s difficulty and identify remaining abilities Assess visual acuity, range of motion and muscle strength in both arms, and range of motion and grip strength in both hands; ability to follow instructions

36. Feeding Problems Interventions Proper positioning and arrangement of the meal tray Provide assistive devices Open milk cartons, cut meat, butter bread, and season food

37. Stomatitis A general term for inflammation of the oral mucosa Medical treatment is directed toward determining the cause and eliminating it; a soft, bland diet may be ordered

38. Vincent’s Infection Bacterial infection that causes a metallic taste and bleeding ulcers in the mouth, foul breath, and increased salivation Topical antibiotics and mouthwashes to treat infection; rest, a nutritious diet, and good oral hygiene

39. Herpes Simplex Caused by the herpes simplex virus, type 1 Ulcers and vesicles in mouth and on lips Occur with upper respiratory tract infections, excessive sun exposure, or stress Spirits of camphor, topical steroids, and antiviral agents as treatment

40. Aphthous Stomatitis (“Canker Sore”) May be caused by a virus Characterized by ulcers of the lips and mouth that recur at intervals Topical or systemic steroids may be used

41. Candida albicans Yeastlike fungus causes the oral condition known as thrush or candidiasis Bluish white lesions on the mucous membranes Patients at high risk include those on steroid or long-term antibiotic therapy Treated with oral or topical antifungal agents; vaginal nystatin tablets can be used like lozenges and allowed to dissolve in the mouth

42. Nursing Care Assessment Pain location, onset, and precipitating factors Record any known illnesses and treatments, including drugs and radiation therapy Describe habits, including diet, oral care practices, alcohol intake, and use of tobacco Assess patient’s stress level Inspect lips and oral cavity for redness, swelling, and lesions

43. Nursing Care Interventions Gentle oral hygiene, prescribed mouthwashes The teeth and tongue can be cleansed with a soft-bristle toothbrush, sponge, or cotton-tipped applicator Medications must be given as ordered

44. Dental Caries A destructive process of tooth decay The only treatment for dental caries is removal of the decayed part of the tooth, followed by filling the cavity with a restorative material

45. Periodontal Disease Begins with gingivitis; progresses to involve the other structures that support the teeth Gums red, swollen, painful, and bleed easily Primarily from inadequate oral hygiene Treatment in early stage: dental care for teeth cleaning and correction of contributing problems Untreated, abscesses develop around the roots, the teeth loosen, and extraction is necessary

46. Figure 38-10

47. Nursing Care Assessment Observe condition of teeth and gums Document missing or broken teeth, caries, redness or lesions of the gums, and gum recession

48. Nursing Care Interventions Most patients are treated for dental and gum conditions in dentists’ offices Interventions directed at minimizing pain until the problem can be corrected by a dentist Provide oral care for patients who cannot do it themselves

49. Oral Cancer Squamous cell carcinoma and basal cell carcinoma Risk factors Cancer of the lip related to prolonged exposure to irritants, including sun, wind, and pipe smoking Factors that increase the risk of cancers inside the mouth include tobacco and alcohol use, poor nutritional status, and chronic irritation

50. Oral Cancer Signs and symptoms Tongue irritation, loose teeth, and pain in the tongue or ear Malignant lesions may appear as ulcerations, thickened or rough areas, or sore spots Leukoplakia: hard, white patches in the mouth; premalignant