Digestive Tract: Let’s Get to the Bottom of it

By: Diana Blum RN MSNMetropolitan Community College

Primary Role

Extract molecules essential for cellular function from fluids and food.

Ingestion, Digestion, Absorption, Elimination

Digestion: breakdown of food into simple nutrient molecules that can be used by cells Process requires:

1. 2. 3.

http://health.discovery.com/centers/digestive/machine.html

Digestive tract

Also called ___________tract muscular tube about 30 ft long Main parts

Mouth Pharynx Esophagus Stomach Small intestine Large intestine Anus

Acessory Organs

Salivary glands Liver Gallbladder Pancreas

Each of the above accessory organs secrete fluid that contain special enzymes that enable breakdown (metabolism) of food

Peritoneum lines the abdominal cavity and covers surface of organs Enables organs to moves without friction during breathing

and digestion

mouth

Teeth cut and grind food Salivary glands secrete saliva

Saliva: Amylase:

Tongue mixes saliva with food and when small enough- forces the food into the pharynx

Pharynx

Shared by digestive and respiratory tracts Joins mouth and nasal passages Contains the epiglottis

Covers the airway (like a trap door) to prevent food from entering respiratory tract

esophagus

Long muscular tube that passes through the diaphragm into the stomach

Gravity helps move the food but it is not essential

Circular, wave like contractions of the muscles propel food down the tract (peristalsis)

Stomach

Widest section of the GI tract Separated from esophagus by the cardiac sphincter Has 3 sections Unique muscle layers churn food by mixing it with gastric

secretions Rennin-starts breakdown of milk proteins Pepsin-partially digests protein HCL acid-partially digests protein Lipase-breaks down fat

Chyme: Pyloric sphincter- keeps food in stomach until it is mixed

properly

Small Intestine

Chyme leaves stomach and enters here Chemical digestion and absorption of

nutrients take place 20 feet long 3 sections

Duodenum-liver and pancreatic enzymes enter here

Jejunum Ileum

Small Intestine Continued

Bile- produced in the liver and stored in the GB break down large fat globs

Pancreatic enzymes-reduce the fat to glycerol and fatty acids to be easily absorbed

3 layers of tissue make up the wall Mucous membrane-secretes digestive enzymes Sucrase, lactase, maltase, lipase, etc. (see table 36-1) Inner layer- covered with Villi (microscopic projections).

Digestive food molecules are absorbed through the villi into the bloodstream

Muscle layers continue to contract moving the chyme into the large intestine.

Large Intestine

No Villi No digestive enzymes Chyme enters through the ileocecal valve Water is absorbed and remaining waste=feces 5 sections

Cecum-1st section..appendix is here Ascending colon-up right abdomen Transverse colon- across abdomen just below waist Descending colon-down the left abdomen

Sigmoid colon-the part of the descending colon between iliac crest and rectum

Rectum-the last 6-8 inches of the large intestine Anus – where waste leaves the body

Age related changes

Teeth mechanically worn down Illness causes increased risk for problems with digestion/elimination Gingiva recedes Tooth loss from caries and periodontal disease Loss of taste buds Xerostomia (dry mouth) is common Walls of esophagus and stomach are thinner with lessened secretions HCL Acid and digestive enzyme production decreases Gastric motor activity slows Delayed gastric emptying Hunger contractions diminish In the large intestine- muscle layer and mucosa atrophy Smooth muscle tone and blood flow decreases Connective tissue increases Constipation is frequent More laxative use

Nursing Assessment

Hx of illness: weight loss, indigestion, change in bowel habit PMH: surgery, trauma, infection, burns, hepatitis, ulcers,

cancer, stomas, meds, allergies Fam Hx: diabetes, CA, ETOH, polyps, obesity, ulcers, GB

Dx System Review: flatus, dyspepsia (indigestion), skin

changes, caries, diff chewing, abd distention, pain, elimination

Functional: nutrition, activity, meal times, likes/dislikes, food beliefs

Physical exam: mucous membranes, condition of mouth/teeth, abd distention, bowel tones, palpation, percussion, rectum/anus for lesions, color, hemorrhoids

diagnostics

Imaging/radiographs: NPO, allergy (iodine, dye, shellfish), consent UGI Barium swallow/enema Endoscope

Upper Lower

Hemmocult-looks for blood

NG

Salem Sump

Tube feedings

Assist pt into fowlers to reduce aspiration. Remains this way for 30 minutes after

Pt remains up at least 30 degree during continuous feeding Check placement for tube in stomach or duodenum prior to

use Air bolus and residual

Check to make sure you have the correct formula Stop feeding if nausea or pain Rinse tube with 30 cc fluid after each bolus Administration

Remove plunger Pinch tube while inserting syringe to avoid stomach content leak Hold barrel about 12 inches above stomach and allow gravity to

infuse Flush after bolus complete

GI decompression

Ng with suction removes fluid and gas

To use Attach to sxn as ordered

Generally low, intermittent is used for single tube Low continuous for dual lumen tubes

Check patency Irrigate routinely Monitor output Assess for flatus Provide comfort measures Once tube in place- securely tape it to nose

feedings

TPN Deliver nutrients directly

into bloodstream via central line

Use sterile technique for dressings and care

Monitor flow rate Monitor blood glucose Label lines

PPN Same as TPN except

goes through peripheral line

Anorexia

Lack of appetite Causes

Nausea Physical/emotional disturbances Environment Decreased sense of smell

Tests: weight, physical, hemoglobin, iron, electrolytes, thyroid

Nursing diagnosis

Imbalanced nutrition less than requirements r/t anorexia

Goal: improved appetite and adequate food intake

AEB: increase in intake, stable or increased wt

Interventions: provide antiemetics prior to meals, remove the bed pan and emesis basin from sight, conceal drains and collection devices, deodorize room

clients with Feed problems

Paralyzed Confused Severe arthritis CVA Visually impaired Etc

FEEDER is demeaning and can threaten self esteem

Interventions for feed problem

Position properly Specially enhanced utensils Open sealed products Cut meats Butter bread Season food after asking client their

preferences See page 751

Role play

Practice feeding classmate a simple meal then reverse.

The person being fed can not speak but understands what is being said

1.How did it feel to be fed?2. What steps did you use?3. How did the feeder feed?4. What did you learn?

Stomatitis

Inflammation of the oral mucosa Mechanical trauma (poor fitting dentures) Irritation 2nd to smoke and ETOH Poor hygiene Radiation Drug therapy

Treatment: soft bland diet, antiviral agents, antibiotics

Vincent’s infection (aka Trench Mouth)

Vincent’s infection

Caused by bacteria Called trench mouth b/c occurred in WWI

field S/S: metallic taste foul breath. Bleeding

ulcers, increased saliva, general infection signs, anorexia

TX: topical antibiotics, mouthwash, rest, nutritious diet, good oral hygiene

Herpes Simplex

Herpes Simplex

Caused by Herpes simplex virus type 1 S/S: ulcers and vesicles in mouth and on lips Other name is cold sore or fever blister Common with people who have upper

respiratory infections, excessive sun exposure, or are stressed

TX: Camphor, topical steroids, antiviral agents

Aphthous Stomatitis (aka canker sore)

Caused by virus S/S: ulcer on lips or

mouth that recur at intervals

TX:topical or systemic steroids

Candidas AlbicansAKA yeast like fungus

Other names: thrush or candidiasis

S/S: bluish white lesions on mucous membrane of mouth

Those at risk: steroid users, long term antibiotic users

TX: oral medications, topical antifungal agents, vaginal nystatin tablets can be used like lozenges

Care and intervention

CARE Usually tx outpt Look at pt symptoms

Onset of symptoms, meds, radiation, habits, diet, ETOH use, and smoking

Describe pain (location, onset, precipitating factors)

INTERVENTION Gentle oral hygiene Prescribed mouthwash Use soft bristle tooth

brush Instruct to take meds as

prescribed (swish and spit, or swish and swallow)

Teach flossing techniques

Dental Caries

Destructive process of tooth decay

Caused by plaque Plaque is made from

bacteria, saliva, and cells that stick to tooth surface

In time if untreated the canal will erode causing intense pain and death of pulp

TX: fluoride, good nutrition

Gingivitis

Beginning of periodontal dx

Inflammation of the gums

s/s: red inflammed tissue of gums, pain, bleeds easily

More frequent in those with missing teeth or whose teeth don’t close properly, vitamin deficiency, anemia

Care and Intervention

CARE Assess pain and

soreness Assess diet and

examinations Examine mouth care

practices

INTERVENTION Minimize pain Gentle mouth care

several times a day Teach client proper

technique Page 752

Oral Cancer

Most life threatening condition of mouth

2 types: Squamous Basal cell

S/S: tongue irritation, loose teeth, tongue pain, ulcerations, leukoplakia (hard white spots), decreased appetite, diff swallowing, weight loss, change in denture fit, hemoptysis

TX: biopsy, surgery, radiation, chemo

Care and Intervention

CARE Assess sun exposure, smoking

habits, ETOH use, fam hx of oral ca,

Interventions Radiation=edema

Dry mouth is issue Good hygiene Special rinses see pg 753 Monitor respirations Suction if ordered Stay on top of pain Soft or liquid diet Monitor I/O Use communication board to talk

with pt BE PATIENT BE A GOOD LISTENER Monitor for infection If graft: monitor color and temp

Parotitis

Inflamed parotid glands S/S: painful swelling near

low jaw, pain increases with mastication

Suseptible: those unable to drink liquids, those weak, no resistance to infection

TX: antibiotics, mouthwash, warm compress

Complications: gland ruptures, surgical drainage or removal may be necessary

Achalasia

Progressive worsening dysphagia

Low esophageal muscles do not relax

Unknown cause TX:dilation, surgery,

botulism toxin, isosorbide dinitrate

Esphageal cancer

Not common Poor prognosis No known cause At risk: smokers, ETOH users,

chronic trauma, poor oral hygiene, spicy food eaters

S/S: progressive dysphagia, substernal pain, epigastric pain, neck/back pain,sore throats, choking, obstruction, weight loss

Esophageal treatment

Esophagectomy Esophagogastrostomy Esophagoenterostomy Dilitation of esophagus Stent Laser tx Chemo Radiation Photodynamic therapy

See page 756

Interventions

Treat pain Daily weight Strict I/O Calorie count Quiet relaxed environment Erect position Chin tuck maneuvers for swallowing Feeding tubes TPN If post op---do not irrigate or reposition Assess pt knowledge Monitor for infection Monitor respirations

N/V

Nausea: feeling of queasiness Pain, pallor, perspiration, cold, clammy skin Causes: irritating foods, infection, radiation, meds, inner ear disorders,

motion sick Vomiting: forceful expulsion of stomach content through the mouth Regurgitation: gentle ejection of fluid or food w/o nausea or retching

TACHYCARDIA AND INCREASED SALIVA are common before vomiting

Complications: loss of fluid and electrolytes, dehydration, metabolic alkalosis, weakness, aspiration

TX: antiemetics, iv fluids, NG tube Interventions: maintain cool room, remove unpleasant stimuli, place in

comfortable position, provide emesis basin, cool damp cloth on head/neck, slow deep breaths, offer mouth care after vomiting, clear liquids

Hiatal Hernia Protrusion of stomach and and lower esophagus up

thru the diaphragm and into chest 2 types:

Sliding: gastroesophageal junction is just above the hiatus. Stomach slides when patient reclines (associated with GERD)

Rolling: gastroesophageal junction remains in place but a portion of the stomach herniates up throu diaphragm through a 2nd ary opening

Complications: ulcerations, bleeding, aspiration Strangulated hernia is one that becomes trapped

without blood flow Causes: asymptomatic to fullness, dysphagia,

eructation (belching), regurgitation, heartburn TX: meds(antacids, H2 receptor blockers, etc), diet,

avoid intra abd pressure, surgery Interventions: stay on top of pain, no food or fluid 2-

3 hours before bed, wooden blocks under top of bed, monitor wt, small frequent meals, avoid fatty foods, caffeine, ETOH, and spicy foods

GERD

Back flow of gastric content from the stomach into the esophagus

Key find: inappropriate relaxation of the low esophagus sphincter

Causes: abnormalities in the LES, ulcers, esophageal surgery, prolonged vomiting, gastric intubation

S/S: can be sudden or gradual, painful burning that moves up and down (common after meals) resolve after antacids, dysphagia, belching

Diagnosis: Based on s/s, raqdiographic studies, endoscopy, bx

Tx: H2 receptor blockers (zantac), prokinetic agents (reglan), proton pump inhibitors (prilosec), surgery

Gastritis

Inflammation of the stomach lining

Mucosal barrier that normally protects stomach breaks down

H pylori is cause S/S: N/V, anorexia, fullness,

pain, hemorrhage Tx: npo until resolve, IVF, Bx,

medication,, bland diet, surgery

Peptic Ulcer

Loss of tissue from digestive lining Caused by pepsin and HCL injure

unprotected tissue LOCATION, LOCATION, LOCATION

Either gastric or duodenal Causes: drugs, infection, stress. S/S: burning pain, nausea, anorexia,

wt loss Complication: hemorrhage, perforation,

obstruction, Tx: meds, diet, stress management

Drug therapy Used to relieve symptoms Antacids are first line of defense

Diet Avoid coffee, tea, meat broth, alcohol, spicy food Frequent small feedings

Management NG tube to sxn if hemorrhage suspected Saline lavage after NG procedure on page 769-772 Vasopressin may help control hemorrage

Table 38-6 discusses surgery tx of peptic ulcer dx

Stomach cancer

25,000 dx each year Most common in men, african

americans, people over 70, low socioeconomic status

S/S: no early signs Late signs: vomiting, ascites, liver

enlargement, abd mass 5 yr survival: 10% No known cause Risk factors: pernicious anemia,

chronic atrophic gastritis, achlorhydria (lack of HCL), smoking, high salt starch pickled food nitrate diet

obesity

Excess body fat Causes: heredity, body build,

metabolism, psychosocial, caloric intake

Complications: heart/lung problems, DM, polycythemia, cholelithiasis, infertility, endometrial cancer, DJD

Tx: wt reduction diet, exercise, medication (pg775), surgery,

malabsorption 1 or more nutrients not absorbed/digested Causes: bacteria, bile salt and digestive enzyme deficiency, alterations in

intestinal mucosa 2 types:

Celiac sprue (tropical, nontropical)- genetic, Non-Tropical: changes in mucosa, impaired absorption Tropical: infectious agent

Lactose intolerance Inherited or aquired Causes: IBS, gastroenteritis, sprue syndrome

S/S: steatorrhea (fatty stools), foul stools, wt loss, decreased libido, easy bruising, edema, anemia, bone pain

Tx: diet, meds, elimate gluten for celiac dx Tropical sprue: oral folate, antibx, vit B12 injections Lactose: no milk or milk products, lactase enzyme, monitor vitamin levels

diarrhea

Loose liquid stools Causes: spoiled foods, allergies,

infection, diverticulosis, cancer, malabsorption, impactions, tube feedings, medications

S/S:cramps, abd pain, urgency Complications: dehydration,

electrolyte imbalance Tx: anti diarrheal drugs, clear

liquids vs npo, possible TPN

constipation

Hard dry infrequent stools Causes: ignoring urge, laxative

use, inactivity, inadequate fluid intake, drugs, brain/spinal cord injury, colon diseases, surgery,

Tx: laxatives, stool softeners,

megacolon

Large intestine looses ability to contract to move feces to rectum

Pts need regular enemas

Fecal impaction

Retention of large amount of stool in the rectum

Some liquid passes around TX: Digital exam/extraction

Intestinal obstruction

Causes by strangulated hernia, tumor, ileus, stricture, volvulus (twisting of bowel)

S/S: vomiting (bile, blood, feces), abd pain, constipation

Complications: electrolyte imbalances, gangrene, perforation, shock, death

TX: gastric decompression, IVF, surgery

appendicitis

Blind patch in the cecum Inflammation of opening of

appendix-bacteria related s/s: pain especially at

mcburney’s point (1/2 way b/w umbilicus and iliac crest), fever, n/v, elevated WBC

Tx: NPO, cold pack

peritonitis

stomach contents enter Abd cavity Complications: fluid shift, abscesses,

adhesions, septicemia, hyovolemic shock, ileus, organ failure

S/S: abd distention, increased pulse and RR, n/v, fever, rigid abd, shock

TX: NG for gastric decompression, IVF, antibiotics, pain meds, surgery

IBS 2 types:

Ulcerative colitis: Begins in rectum, expands to cecum

Crohn’s: regional enteritis Affects all GI tract Most common= terminal ileum

Causes: unknown S/S of IBS: constipation, diarrhea, bloody stools, abd

cramping, wt loss S/S crohn’s: variable, n/v, pain, cramping, abd

tenderness, fever, night sweats, malaise, joint pain Complications:hemorrhage, obstruction, perforation,

abscess, fistulas, megacolon, colon cancer, joint inflammation, diarrhea, stones, liver dx, electrolyte imbalances

Tx: meds (page 786), low roughage diet without milk, nicotine patches, surgery with possible removal of intestine

Diverticulosis

Small sac like pouches in intestinal wall Most in sigmoid colon Risk factors: lack of dietary factors, age,

constipation, obesity, emotional tension S/S: asymptomatic, constipation,

diarrhea, pain, rectal bleed, n/v, urinary problems

Complications: bleed, obstruct, perforation, peritonitis, fistula

Tx: high residue diet, no spicy foods, no seedy food, stool softener, meds, page 788, surgery

Colorectal CA

3rd most common in women High fat low fiber diet is risk factor Most found in rectum or low

sigmoid S/S: depend on location,

cramping, anemia, weakness, fatigue, left sided= more obvious changes

TX: surgery, colostomy, chemo, radiation

Polyps

Small benign growths that can become malignant

Multiple polyps called gardner’s syndrome or familial polyposis

S/S:asymptomatic Complications: bleed, obstruction Tx: removal, colectomy

hemorrhoids

Dilated veins in rectum May be internal or external Risk factors: increased

pressure in rectal blood vessels from constipation, pregnancy, prolonged sit or stand

S/S: pain, bleed, itching, TX : surgery, ice followed by

heat, medication

Anorectal abscess

Infection in the tissue around rectum

S/S: pain, swelling, redness, tenderness, diarrhea, bleeding, itching, discharge

Tx: antibx, incision, drainage, surgery, ice packs, pt education r/t to cleansing

Anal fissure

Laceration b/w anus and perianal skin

r/t constipation, diarrhea, crohn’s, TB, leukemia, trauma, childbirth

S/S: pain with defecation, bleeding, itching, urinary frequency, urinary retention, dysuria

Tx: heal spontaneously, sitz bath, stool softeners, pain meds, surgery

Anal fistula

Abnormal opening b/w anal canal and perianal skin

Causes: abscess, IBD, TB S/S: pruritis, discharge Tx: sitz bath, surgery, temporary

colostomy, pain meds

Pilonidal cyst

Painful and swollen

May form abscess

Surgery may be needed to fix

PT EDUCATION

Handwashing Proper food handling Food poisoning Stress management When to call doctor Page 793

THE END