Digestive System - Medical Surgical Nursing Handout [PDF]

2/8/2025 Digestive System (Gastrointestinal Tract and its Accessory Organs) Medical-Surgical Nursing 1 Functions of the Digestive System 2 1  2/8/2025 3 4 2 ...

2/8/2025 Digestive System (Gastrointestinal Tract and its Accessory Organs) Medical-Surgical Nursing 1 Functions of the Digestive System 2 1  2/8/2025 3 4 2  2/8/2025 5 Digestion Mechanical Chewing (mouth) Swallowing (esophagus) Involuntary phase is controlled by Medulla Oblongata Epiglottis covers the trachea to prevent aspiration of food to the lungs Churning (stomach) Segmentation contraction (small intestine) 6 3  2/8/2025 Digestion Chemical: Mouth – ptyalin/salivary amylase (by parotid, submaxillary, sublingual glands) Stomach (partially digests food to form chyme – 30 min to hours) hydrochloric acid (secreted by glands in the stomach and can have a pH of 1; digests food chemically and destroys most ingested bacteria) Pepsin – digestion of protein Intrinsic factor – necessary for absorption of Vit. B12 in the ileum Small Intestine (3-6 hours) Duodenum (receives digestive secretions from the Pancreas, Liver, and Gallbladder) Pancreatic secretions are bicarbonate-concentrated making it neutralize the acidic chyme. This contains digestive enzymes: trypsin (for protein), amylase (for starch), and lipase (for fats) Bile emulsifies fats, produced by the Liver and stored in the Gallbladder Where absorption of nutrients mostly occurs 7 Digestion Chemical: Colon/large intestine Colonic secretions added to residual material: electrolyte solution (alkaline) and mucus Reabsorption of water and electrolytes Gut microbiome/microbiota Protection and defense Vitamin synthesis 8 4  2/8/2025 Excretion Feces undigested foodstuffs, inorganic materials, water, and bacteria about 75% fluid and 25% solid material brown color of the feces results from the breakdown of bile by the intestinal bacteria. The odor is the result of chemicals formed by intestinal bacteria 9 Age-related changes in the Gastrointestinal System and its implications: 10 5  2/8/2025 Age-related changes in the Gastrointestinal System and its implications: 11 Age-related changes in the Gastrointestinal System and its implications: 12 6  2/8/2025 Common Symptoms that may result to patients seeking healthcare: Abdominal Pain Dyspepsia Gas Nausea and Vomiting Diarrhea Constipation 13 Common Symptoms: GI Disorders An unpleasant sensory and emotional experience associated with actual or Pain potential tissue damage or described in terms of such damage 14 7  2/8/2025 Common Symptoms: GI Disorders Types and Categories of Pain: Acute Pain – involves tissue damage, short duration, expected to resolve with normal healing Pain Chronic/ Persistent Pain - can be cancer or non-cancer in origin. - may be intermittent, occurring with flares, or it may be continuous. Some cancer patients experience breakthrough pain (BTP) where they ave continuous chronic pain and also experience more intense acute exacerbations of pain periodically 15 Common Symptoms: GI Disorders Types and Categories of Pain: Nociceptive Pain (Normal processing of stimuli that damages tissues or has the potential to do so if prolonged) - Somatic (Arises from bone joint, muscle, skin, or connective tissue. It is usually described as aching or throbbing in quality and is well Pain localized) - Visceral (Arises from visceral organs, such as the GI tract and pancreas. Can be due to tumor involvement or obstruction.) Neuropathic Pain (Abnormal processing of sensory input by the peripheral or central nervous system or both) - E.g. Phantom pain, Diabetic Neuropathy, Trigeminal Neuralgia 16 8  2/8/2025 Common Symptoms: GI Disorders Location: Ask the patient to state or point to the area(s) of pain on the body. Sometimes allowing patients to make marks on a body diagram is helpful in gaining this information. Pain Quality: sharp, shooting, burning Onset and Duration: when the pain started and whether intermittent or constant Aggravating and relieving factors: what makes the pain worse and what makes it better 17 Common Symptoms: GI Disorders Intensity: Numeric Rating Scale (NRS) – patient rates pain from 0-10 Wong Baker FACES Pain Rating Scale 6 cartoon faces with word descriptors such as smiling face with “no pain” to a frowning-tearful Pain face with “worst pain”. Patient determines pain rating. Can be used in adults and children from 3 yrs old FLACC Used in young children (0-2) by assigning scores (0- 10) after assessing the following: Facial expression Leg Movement Activity Crying Consolability 18 9  2/8/2025 Common Symptoms: GI Disorders Intensity: CPOT (Critical Care Pain Observation Tool) indicated for use in patients in critical-care units who cannot self-report pain, whether or not they may be intubated. patterned after the FLACC. Pain 19 Common Symptoms: GI Disorders Reassessment of Pain: - With each new report of pain - Before and after administration of analgesic treatment - Generally 15-30 min after parenteral Pain administration - 1-2 hours after oral administration 20 10  2/8/2025 21 Common Symptoms: GI Disorders Upper abdominal discomfort associated with eating (commonly called indigestion)— is the most common symptom of patients with GI dysfunction. Dyspepsia Indigestion is an imprecise term that refers to a host of upper abdominal or epigastric symptoms such as pain, discomfort, fullness, bloating, early satiety, belching, heartburn, or regurgitation. 22 11  2/8/2025 Common Symptoms: GI Disorders Accumulation of gas in the GI tract can result to: Belching - expulsion of gas from the stomach through the mouth Intestinal gas Flatulence - expulsion of gas from the rectum With food intolerance or gallbladder disease, patients often complain about bloating, distention, or feeling “full of gas” with excessive flatulence 23 Common Symptoms: GI Disorders Nausea - a vague, uncomfortable sensation of sickness or “queasiness” that may or may not be followed by vomiting Nausea and - Commonly caused by distention of upper GI tract and duodenum, or may be an early Vomiting sign of a disease - can be triggered by odors, activity, medications, or food intake 24 12  2/8/2025 Common Symptoms: GI Disorders Vomiting - forceful emptying of the stomach and intestinal contents through the mouth - emesis/vomitus may contain undigested food, Nausea and blood (hematemesis), bilious materials mixed with gastric juices Vomiting - Acute onset of emesis with bright-red or coffee ground color may indicate upper GI bleeding 25 Common Symptoms: GI Disorders This signals colonic dysfunction or disease. Diarrhea - abnormal increase in the frequency and liquidity of the stool or in daily stool weight or volume Changes in - commonly occurs when the contents move so Bowel Habits rapidly through the intestine and colon that there is inadequate time absorption/ reabsorption 26 13  2/8/2025 Common Symptoms: GI Disorders Constipation - a decrease in the frequency of stool, or stools that are hard, dry, and of smaller volume than typical—may be associated with anal discomfort and rectal bleeding Changes in Bowel Habits 27 Common Symptoms: GI Disorders Stool is normally light to dark brown (can be affected by disease process or ingestion of certain food/medications) Changes in Stool Characteristics 28 14  2/8/2025 Common Symptoms: GI Disorders Blood in the Stool: Black-tarry color (Melena) - upper GI Tract bleeding Bright or dark red – Lower GI Tract bleeding * Streaking of blood on the surface of the stool Changes in or blood is noted on toilet tissue may indicate lower rectal/anal bleeding Stool Characteristics 29 Common Symptoms: GI Disorders Other common abnormalities: Changes in Stool Characteristics 30 15  2/8/2025 Review: 31 Bowel Sounds Assessed using a stethoscope to hear clicks and gurgles (5- 30/min) Designated as normal, hypoactive, hyperactive, absent Borborygmus (“stomach growling”) is heard as a loud prolonged gurgle 32 16  2/8/2025 33 Serum Laboratory Tests (E.g. liver function test, tumor markers, prothrombin time/partial prothrombin time) Stool Tests inspecting the specimen for: - consistency, color, and occult (not visible) Diagnostic Tests blood. - Additional studies, including fecal urobilinogen, fecal fat, nitrogen, Clostridium difficile, fecal leukocytes, calculation of stool osmolar gap, parasites, pathogens, food residues, and other substances, require laboratory evaluation 34 17  2/8/2025 Breath Tests Hydrogen Breath Test – to evaluate carbohydrate absorption, diagnosis of bacterial overgrowth in the intestine and short- bowel syndrome Urea Breath Test – to detect the presence of Diagnostic Tests H. pylori that can cause peptic ulcer 35 Abdominal Ultrasonography noninvasive diagnostic technique in which high-frequency sound waves are passed into internal body structures, and the ultrasonic echoes are recorded on an oscilloscope as they strike tissues of different densities Diagnostic Tests useful in the detection of an enlarged gallbladder or pancreas, the presence of gallstones, an enlarged ovary, an ectopic pregnancy, or appendicitis. 36 18  2/8/2025 Abdominal Ultrasonography Instruct patient to fast 8-12 hours before ultrasound to decrease the amount of gas in the bowel For gallbladder studies – eat a fat-free meal the evening before the test Diagnostic Tests Barium studies should be conducted after the ultrasound as barium may interfere the transmission of soundwaves If patients are given moderate sedation, observe for 1 hour to assess for level of consciousness, orientation and ability to ambulate 37 Upper Gastrointestinal Fibroscopy/ Esophagogastroduodenoscopy - Around 30-min procedure - For viewing and for therapeutic purpose (E.g. removal of bile duct stones, treat gastric bleeding and esophageal varices, and to Endoscopic obtain biopsy specimen) Procedures 38 19  2/8/2025 Nursing considerations: - Patient should be on NPO for 8 hours prior to examination - Given local anesthetic gargle/spray prior to the introduction of the scope, Midazolam for moderate sedation (with loss of gag reflex), Endoscopic Atropine to reduce secretions, Glucagon to relax smooth muscle Procedures - Position: left lateral position to facilitate clearance of pulmonary secretions and provide smooth entry of the scope 39 40 20  2/8/2025 Nursing considerations: After the procedure: - assessment includes level of consciousness, vital signs, oxygen saturation, pain level, and monitoring for signs of perforation (i.e., pain, bleeding, unusual difficulty swallowing, rapidly Endoscopic elevated temperature) - After return of gag reflex, may offer lozenges, Procedures saline gargle, and oral analgesic agents to reduce minor throat discomfort - Patient must remain in bed until FULLY ALERT - Someone should stay with the patient until the morning after the procedure. Because of sedation, many patients will not remember post-procedure instructions. 41 Colonoscopy - Direct visual inspection of the large intestine through a flexible fiberoptic colonoscope (procedure is around 1 hour) - Can capture still and video recordings of the colon, obtain specimen for biopsy, remove Endoscopic polyps Procedures - For diagnostic aid and screening - Position: left side lying with legs drawn towards the chest 42 21  2/8/2025 Nursing consideration: - Colon cleansing - Laxative for 2 nights prior to procedure and fleet/saline enema until the return is clear in the morning of the test - Commonly, PEG electrolyte lavage solutions are used for effective cleansing Endoscopic - Entire solution is ingested the night before the procedure (non-split regimen) Procedures - Half ingested the night before and and half in the morning 3 hours prior to the procedure (split regimen) - Diet: Clear liquid or low residue diet a day before the procedure 43 44 22  2/8/2025 Nursing consideration: - Possible complication: cardiac arrhythmias and respiratory depression resulting from the medications given, vasovagal reactions, and circulatory overload or hypotension resulting from overhydration or underhydration during bowel preparation. Endoscopic Continuously monitor cardiac and respiratory Procedures function and oxygen saturation - Possible complication (after procedure): bowel perforation Watch out for signs: e.g., rectal bleeding, abdominal pain or distention, fever, focal peritoneal signs). 45 Nursing consideration: - Midazolam has amnesic effect, provide written instructions - Instruct patient to report any signs of bleeding Endoscopic Procedures 46 23  2/8/2025 Anoscopy (anus), Proctoscopy (rectum), Sigmoidoscopy (sigmoid) Endoscopic examination of the anus, rectum, and sigmoid and descending colon is used to evaluate chronic diarrhea, fecal incontinence, ischemic colitis, and lower GI hemorrhage and to observe for ulceration, fissures, abscesses, tumors, Endoscopic polyps, or other pathologic processes. Procedures - Limited bowel preparation: warm tap water or Fleet enema until returns are clear, diet restrictions and sedation are not required. - Monitor for rectal bleeding and signs of intestinal perforation (i.e. fever, rectal drainage, abdominal distention, pain) - Patient can resume regular activities and diet after the procedure 47 Laparoscopy (Peritoneoscopy) Visualization of the intra-abdominal organs using a fiberoptic laparoscope by first, creating a pneumoperitoneum (injecting carbon dioxide into the peritoneal cavity to separate the intestines from the pelvic organs). Endoscopic Procedures - Allows visualization, obtaining specimen, and even perform laparoscopic surgeries (e.g. removal of gall bladder) - Minimally invasive procedure but the patient will be put on general anesthesia 48 24  2/8/2025 49 Parotitis Inflammation of the parotid gland (most common) - Epidemic parotitis – caused by mumps (viral infection) - Bacterial parotitis – commonly caused by Staphylococcus aureus (travels from the mouth through the salivary ducts Disorders of the Salivary Glands 50 25  2/8/2025 Parotitis Inflammation of the parotid gland (most common) - Signs and Symptoms: - Sudden onset associated with signs of systemic infection (fever and chills) - Pain in the ear Disorders of the - Swelling of the gland which may cause dysphagia, overlying skin becomes red and Salivary Glands shiny 51 Parotitis Inflammation of the parotid gland (most common) - Medical Management: - Cold packs - Ensuring adequate nutrition and fluid intake - Good oral hygiene Disorders of the - Discontinue medications that can diminish salivation (tranquilizers and diuretics) Salivary Glands - Antibiotics (for bacterial parotitis). If ineffective, parotidectomy (surgical draining of the gland) 52 26  2/8/2025 Sialadenitis Inflammation of the salivary glands which can be caused by: - Infection (commonly S. aureus) - Dehydration - Radiation therapy - Stress Disorders of the - Malnutrition - Salivary gland calculi Salivary Glands - Improper oral hygiene Additional management: - Sialogogues (substances that trigger saliva flow like hard candy or lemon juice) - Sialendoscopy (used in chronic inflammation; for visualization of the gland and instillation of medication – antibiotic, corticosteroid, or irrigation) 53 Sialolithiasis (Salivary Calculus) Salivary calculi (stones) that mostly occur in the submandibular gland. Mainly formed from calcium phosphate. Management: Sialendoscopy (standard), surgery, lithotripsy Disorders of the Salivary Glands 54 27  2/8/2025 Stomatitis/Oral Mucositis - Mouth ulcers - Can be induced by chemotherapy Saline/sodium bicarbonate rinses - ½ to 1 tsp of baking soda: 8 oz of warm water Oral Care - ¼ tsp salt: 8oz of warm water Management 55 Achalasia a rare disorder characterized by absent or ineffective peristalsis of the distal esophagus and failure of the lower esophageal sphincter to relax in response to swallowing. This results in narrowing above the stomach and gradual dilation of the esophagus in the upper chest Disorders of the Signs and Symptoms: Esophagus - Dysphagia, particularly with solid food - Sensation of food sticking in the lower esophagus - Regurgitation of undigested food (spontaneous or intentional) - Noncardiac chest pain or epigastric pain - Pyrosis (heartburn) similar to GERD - Commonly misdiagnosed as GERD 56 28  2/8/2025 Achalasia Assessment and Diagnostic Finding: - X-ray shows bird-beak deformity (esophageal dilation above the narrowing at the lower gastroesophageal sphincter) Disorders of the - May perform barium swallow, chest CT scan, and endoscopy Esophagus Confirmatory test: High-resolution manometry (peristalsis, contraction amplitudes, and esophageal pressure is measured by a radiologist or gastroenterologist) 57 Achalasia Management: - Pneumatic dilation (typically 2 dilations are required) - Esophagomyotomy or Heller myotomy Disorders of the - Cutting the esophageal muscle fibers Esophagus 58 29  2/8/2025 59 Esophageal Spasm - Jackhammer esophagus (hypercontractile esophagus with spasms occurring in 205 of swallows at a very high amplitude, duration, and length) - Diffuse esophageal spasm (DES) – normal in amplitude, premature/uncoordinated - Type III (spastic) achalasia – lower esophageal sphincter obstruction with esophageal spasm Disorders of the Management: Esophagus - smooth muscle relaxants such as calcium channel blockers and nitrates may be used to reduce the pressure and amplitude of contractions - Botulinum toxin (if other interventions cannot be tolerated) - Proton pump inhibitors (PPI) – if symptoms of GERD occur - Small frequent feedings and soft diet 60 30  2/8/2025 Hiatal Hernia opening in the diaphragm through which the esophagus passes becomes enlarged, and part of the upper stomach moves up into the lower portion of the thorax Two (2) Types: Disorders of the - Sliding Esophagus - Paraesophageal Diagnosis: - Xray studies, barium swallow, EGD 61 62 31  2/8/2025 Hiatal Hernia Management: - Small feedings, Advise patient not to recline for 1 hour after eating, Elevate head of bed to prevent hernia from sliding Disorders of the - Commonly, surgery performed is directed to Esophagus control GERD symptoms. Surgical repair is indicated for patients with more extreme cases (gastric outlet obstruction/suspected gastric strangulation which may result in ischemia, necrosis, or perforation of the stomach) 63 Diverticulum an out-pouching of mucosa and submucosa that protrudes through a weak portion of the musculature of the esophagus. Disorders of the Esophagus 64 32  2/8/2025 Diverticulum May occur in 3 areas: - pharyngoesophageal (upper) Zenker diverticulum (most common) – due to dysfunctional sphincter - midesophageal (middle) - epiphrenic (lower) – lower esophageal sphincter Disorders of the not properly functioning/ esophageal motor disorder Esophagus Signs and symptoms: - Dysphagia - Fullness in the neck - Halitosis - Belching - Regurgitation of undigested food 65 Diverticulum Diagnosis: Barium Swallow to determine full extent Manometric Studies for epiphrenic diverticula (to rule out motor disorder) Disorders of the No endoscopy (risk for perforation) Esophagus No blind insertion of NG tube Management: Surgery 66 33  2/8/2025 Gastroesophageal Reflux Disease (GERD) backflow of gastric or duodenal contents into the esophagus characterized by pyrosis (heartburn) and regurgitation Causes: incompetent lower esophageal sphincter, pyloric Disorders of the stenosis, hiatal hernia, or a motility disorder. Esophagus Risk of occurrence increases with aging and other diseases (IBS, BE, obstructive airway disorder, peptic ulcer and angina). Associated with tobacco use, coffee drinking, alcohol consumption, and gastric infection with Helicobacter pylori GERD can result into dental erosion, ulcerations in the pharynx and esophagus, laryngeal damage, esophageal strictures, adenocarcinoma, and pulmonary complications 67 Gastroesophageal Reflux Disease (GERD) Assessment and Diagnosis: - Ambulatory pH monitoring (gold standard) - transnasal catheter placement or endoscopic wireless capsule placement for approximately 24 hours Disorders of the - Proton Pump Inhibitor (PPI) trial Esophagus 68 34  2/8/2025 Gastroesophageal Reflux Disease (GERD) Management: - Lifestyle modification (tobacco cessation, limiting alcohol, weight loss, elevating the head of the bed, avoiding eating before bed, and altering the diet) Disorders of the - Pharmacologic - Surgical (Nissen fundoplication - wrapping of a Esophagus portion of the gastric fundus around the sphincter area of the esophagus) 69 70 35  2/8/2025 71 72 36  2/8/2025 73 Barrett Esophagus A condition where the lining of the esophagus is altered and occurs in association with: - Family history - Esophageal adenocarcinoma (EAC) - GERD - Smoking Disorders of the - Obesity *Patient complains of GERD symptoms and/or that of Esophagus peptic ulcer/esophageal stricture Management: Endoscopic ablation techniques (to prevent dysplasia which is indicative of early EAC) followed by surveillance biopsies (3-5 yrs after procedure). Endoscopic resection/high-frequency ablation for progression of dysplasia 74 37  2/8/2025 75 Gastritis Inflammation of the gastric mucosa which can be: - Acute (few hours to days) erosive – caused by local irritants (aspirin, Disorders of the NSAIDs, corticosteroids, alcohol, radiation therapy. A strong acid/alkali can cause gangrene, Stomach perforation, scarring (resulting to pyloric stenosis) non-erosive – caused by H. pylori infection - Chronic (due to repeated exposure to irritating agents or frequent acute episodes) 76 38  2/8/2025 77 78 39  2/8/2025 Gastritis Medical Management - Antibiotics - Antidiarrheal - H2 Receptor Antagonists Disorders of the - Proton Pump Inhibitors Stomach - Prostaglandin E1 Analogue 79 80 40  2/8/2025 81 82 41  2/8/2025 83 84 42  2/8/2025 85 Gastritis Nursing Management (Acute Gastritis): - Promote optimal nutrition Allow the gastric mucosa to heal: NPO for few days, IV therapy, offer ice chips if Disorders of the symptoms subside, Stomach Introduce solid food, monitor for repeated episodes of gastritis Discourage caffeine, alcohol and smoking - Relieve pain (avoiding gastric irritants) - Promote fluid balance - Be alert for signs of bleeding 86 43