Digestive System - Medsurg

DIGESTIVE SYSTEM- MEDSURG PRELIM Functions of the Digestive System  All cells of the body require nutrients. These nutrients are derived from the intake of food that contains proteins, fats, carbohydrates, vitamins, minerals, and cellulose fibers and other vegetable matter, some of which has no nutritional value. Major functions of the GI tract include: Digestion: Breakdown of food particles into the molecular form for digestion Absorption into the bloodstream of small nutrient molecules produced by digestion Elimination of undigested unabsorbed foodstuffs and other waste products After food is ingested, it is propelled through the GI tract, coming into contact with a wide variety of secretions that aid in its digestion, absorption, or elimination from the GI tract. KK • Epiglottis covers the trachea to prevent aspiration of food to the lungs • Churning (stomach): the process by which the stomach's muscular walls mix food with gastric juices. This process breaks down food into smaller pieces and prepares it to move into the small intestine. • Segmentation contraction (small intestine): localized contractions of the small intestine's circular muscles that mix, separate, and churn chyme. CHYME: partially digested food Chemical • Mouth - ptyalin/salivary amylase( formof amylase that is found in the saliva) is produced by: 1. parotid, 2. Submaxillary 3. 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 -It digests food chemically and destroys most ingested bacteria • Pepsin-digestion of protein • Intrinsic factor - necessary for absorption of Vit. B12 in the ileum.  PERNICIOUS ANEMIA- if indi namaka absorb ang intrinsic factor ka vitamin b12 • Small Intestine food typically spends around 3-6 hours in the small intestine, Duodenum (receives digestive secretions from the Pancreas, Liver, and Gallbladder) - Alkaline because ginasecret ya sa accessory organ ang bicarbonate nga ga neutralize ang acid  Digestion -The stomach's lining is protected from hydrochloric acid by mucus, a thick, alkaline fluid produced by mucous cells in the stomach wall. Mechanical  • Chewing (mouth) • Swallowing (esophagus)/ IF MAY DAMAGE ANG MEDULLA OBLONGATA MA ALTER ANG SWALLOWING • Involuntary phase is controlled by Medulla Oblongata Pancreatic secretions are bicarbonateconcentrated making it neutralize the acidic chyme. This contains digestive enzymes: 1. trypsin (for protein) 2. amylase (for starch) 3. and lipase (for fats) DIGESTIVE SYSTEM- MEDSURG PRELIM  Bile: emulsifies fats, produced by the Liver and stored in the Gallbladder  Where absorption of nutrients mostly occurs • 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. EXCRETION  Feces or stool: undigested food stuffs, inorganic materials, water, and bacteria  BROWN COLOR of feces results from the breakdown of bile by the intestinal bacteria  THE ODOR: is the result of chemicals formed by intestinal bacteria KK VILLI- tiny, flexible projections that line the lumen of the small intestine Common Symptoms that may result to patients seeking healthcare: 1. 2. 3. 4. 5. 6. Abdominal Pain Dyspepsia Gas Nausea and Vomiting Diarrhea Constipation PAIN - An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage Types and Categories of Pain: 1. ACUTE PAIN - involves tissue damage, short duration, expected to resolve with normal healing 2. 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 (breakthrough-combined acute and chronic pain) 3. NOCICEPTIVE PAIN (Normal processing of stimuli that damages tissues or has the potential to do so if prolonged) - normal process of pain in body 2 types: SOMATIC (Arises from bone joint, muscle, skin, or connective tissue. It is usually described as aching or throbbing in quality and is well localized) VISCERAL (Arises from visceral organs, such as the GI tract and pancreas. Can be due to tumor involvement or obstruction.) 4. NEUROPHATIC PAIN (Abnormal processing of sensory input by the peripheral or central nervous system or both) - E.g. Phantom pain, Diabetic Neuropathy, Trigeminal Neuralgia DIGESTIVE SYSTEM- MEDSURG PRELIM KK Assessing pain DYSPEPSIA 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.  QUALITY: sharp, shooting, burning ONSET & DURATION: when the pain started and whether intermittent or constant AGGRAVATING AND RELIEVING FACTORS: what makes the pain worse and what makes it better Intensity:  Numeric Rating Scale (NRS) - patient rates pain from 0-10 if conscious (common in ph)  Wong Baker FACES Pain Rating Scale: 6 cartoon faces with word descriptors such as smiling face with "no pain" to a frowning tearful face with "worst pain",  Patient determines pain rating  Can be used in adults and children from 3 yrs old   - FLACC (medical professional)  Used in young children (0-2) by assigning scores (0-10) after assessing the following: 1. Facial expression 2. Leg Movement 3. Activity 4. Crying 5. *Consolability 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. Reassessment of Pain:   With each new report of pain Before and after administration of analgesic treatment  Generally 15-30 min after parenteral administration  1-2 hours after oral administration  indigestion Upper abdominal discomfort associated with eating (commonly called indigestion) is the most common symptom of patients with GI dysfunction. 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 (tig-ab), heartburn, or regurgitation. INTESTINAL GAS Accumulation of gas in the GI tract can result to: Belching - expulsion of gas from the stomach through the mouth. (TIGAB) Flatulence - expulsion of gas from the rectum. (UTOT) With food intolerance or gallbladder disease, patients often complain about bloating, distention, or feeling "full of gas" with excessive flatulence NAUSEA AND VOMITING NAUSEA - a vague, uncomfortable sensation of sickness or "queasiness" that may or may not be followed by vomiting - Commonly caused by distention of upper GI tract and duodenum, or may be an early sign of a disease - can be triggered by odors, activity, medications, or food intake VOMITING (EMESIS/VOMITUS) - forceful emptying of the stomach and intestinal contents through the mouth - emesis/vomitus may contain undigested food, blood (hematemesis), bilious materials mixed with gastric juices - Acute onset of emesis with bright-red or coffee ground color may indicate upper GI bleeding CHANGES IN BOWEL HABITS  This signals colonic dysfunction or disease. DIGESTIVE SYSTEM- MEDSURG PRELIM KK Diarrhea (LOW POTASSIUM) - abnormal increase in the frequency and liquidity of the stool or in daily stool weight or volume - commonly occurs when the contents move so rapidly through the intestine and colon that there is inadequate time absorption/ reabsorption 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  Small, dry, rock-hard masses occasionally streaked with blood  Loose, watery stool that may or may not be streaked with blood 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 CHANGES IN STOOL CHARACTERISTICS HEALTH PROMOTION Stool is normally light to dark brown (can be affected by disease process or ingestion of certain food/medications) FOOD AND COLOR MEDICATIONS LEAFY GREEN SPINACH, KALE THAT VEGETABLES, ALTER GREEN BEETS/ REDGELATIN/ TOMTO SOUP/ FOOD COLORING RED BISMUTH/IRON/ LICORIE BLACK BARIUM BLACK STOOL Denture Care * Brush dentures twice a day. * Clean well under partial dentures, where food particles tend to get caught. * Consume nonsticky foods that have been cut into small pieces; chew slowly. * Remove dentures at night and soak them In water or a denture product. Never put dentures in hot water, because they may warp. (deform) MILKY WHITE * Rinse mouth with war salt water in the moming, after meals, and at bedtime. * See dentist regularly to assess and adjust fit. Blood in the Stool: DIAGNOSTIC TEST Black-tarry color (Melena) - upper GI Tract bleeding SERUM LABORATORY TEST (E.g. liver function test, tumor markers, prothrombin time/partial prothrombin time - for blood clot) Bright or dark red - Lower GI Tract bleeding Streaking of blood on the surface of the stool or blood is noted on toilet tissue may indicate lower rectal/anal bleeding Occult blood- no discoloration in feces/not visible OTHER COMMON ABNORMALITIES  Bulky, greasy, foamy stools that are foul in odor and may or may not float  Light gray or clay-colored stool, caused by a decrease or absence of conjugated bilirubin  Stool with mucus threads or pus that may be visible on gross inspection of the stool STOOL TESTS inspecting the specimen for:  consistency, color, and occult (not visible) blood.  Additional studies, including fecal urobilinogen, fecal fat, nitrogen, Clostridium difficile, fecal leukocytes, calculation of stoo! osmolar gap, parasites, pathogens, food residues, and other substances, require laboratory evaluation BREATH TESTS * HYDROGEN BREATH TEST - to evaluate carbohydrate absorption, diagnosis of bacterial overgrowth in the intestine and short-bowel syndrome DIGESTIVE SYSTEM- MEDSURG PRELIM * UREA BREATH TEST - to detect the presence of H. pylori that can cause peptic ulcer 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   useful in the detection of an entarged gallbladder or pancreas, the presence of gallstones, an enlarged ovary, an ectopic pregnancy, or appendicitis. NURSING CONSIDERATION  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  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 ENDOSCOPIC PROCEDURES Upper Gastrointestinal FibroscopyEsophagogastroduodenoscopy (EDG) esophagous, duodenum, stomach   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 obtain biopsy specimen)  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), Atropine to reduce secretions, Glucagon to relax smooth muscle  - Position: LEFT LATERAL POSITION to faciutate clearance of pulmonary secretions and provide smooth entry of the scope KK    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 elevated temperature) After return of gag reflex, may offer: 1. LOZENGES 2. SALINE GARGLE 3. 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 remembe post-procedure instructions. DIGESTIVE SYSTEM- MEDSURG PRELIM Colonoscopy  Direct visual inspection of the large intestine KK - Midazolam has amnesic effect, provide written instructions through a flexible fiberoptic colonoscope  (procedure is around 1 hour)  Can capture still and video recordings of the colon, obtain specimen for biopsy, remove polyps  For diagnostic aid and screening Position: left side lying with legs drawn towards the chest 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   Entire solution is ingested the night before the procedure (non-split regimen) 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 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. Continuously monitor cardiac and respiratory 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). - Instruct patient to report any signs of bleeding DIGESTIVE SYSTEM- MEDSURG PRELIM Endoscopic Procedures 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 G hemorrhage  and to observe for ulceration  Fissures  Abscesses  Tumor  polyps, or other pathologic processes.  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 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). KK Signs and Symptoms:  Sudden onset associated with signs of systemic infection (fever and chills)  Pain in the ear  Swelling of the gland which may cause dysphagia, overlying skin becomes red and shiny Medical Management:  Cold packs  Ensuring adequate nutrition and fluid intake  Good oral hygiene  Discontinue medications that can diminish salivation (tranquilizers and diuretics) dapat mag salivate salivate Antibiotics (for bacterial parotitis).  If ineffective, Parotidectomy (surgical draining of the gland) Sialadenitis Inflammation of the salivary glands which can be caused by: ● Infection (commonly S. aureus) ● Denvaration ● Radiation therapy ● stress ● Malnutrition ● Salivary gland calculi ● 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 - 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 Sialolithiasis (Salivary Calculus) Disorders of the Salivary Glands Parotid gland Salivary calculi (stones) that mostly occur in the submandibular gland. 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 Mainly formed from calcium phosphate. Management: Sialendoscopy (standard), surgery, lithotripsy( use of shock wave) DIGESTIVE SYSTEM- MEDSURG PRELIM KK Esophageal Spasm ORAL CARE MANAGEMENT  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  ¼ tsp salt: 8oz of warm water Disorders of the Esophagus 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 Signs and Symptoms:  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 Assessment and Diagnostic Finding:   X-ray shows bird-beak deformity (esophageal dilation above the narrowing at the lower gastroesophageal sphincter) 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 Management:  smooth muscle relaxants such as calcium channel blockers and nitrates mav be use to reduce the pressure an amputude or contractions  Botulinom toxin (if other cannot he tolerated)  Proton pump inhibitors (PPI) - if symptoms of GERD occur  Small frequent feedings and soft diet 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: 1. Sliding 2. Paraesophageal Diagnosis: - Xray studies, barium swallow, ED May perform barium swallow, chest CT scan, and endoscopy Confirmatory test: High-resolution manometry (peristalsis, contraction amplitudes, and esophageal pressure is measured by a radiologist or gastroenterologist) Management:  Pneumatic dilation (typically 2 dilations are required)  Esophagomyotomy or Heller myotomy ( Cutting the esophageal muscle tibers) Management:  Small feedings, Advise patient not to recline for 1 hour after eating, Elevate head of bed to prevent hernia from sliding   Commonly, surgery performed is directed to 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) DIGESTIVE SYSTEM- MEDSURG PRELIM Diverticulum  an out-pouching of mucosa and submucosa that protrudes through a weak portion of the musculature of the esophagus. May occur in 3 areas: 1. pharyngoesophageal (upper)  Zenker diverticulum (most common) – due to dysfunctional sphincter 2. midesophageal (middle) 3. epiphrenic (lower) – lower esophageal sphincter not properly functioning/ esophageal motor disorder Signs and symptoms:  Dysphagia  Fullness in the neck  Halitosis  Belching  Regurgitation of undigested food Diagnosis: Barium Swallow to determine full extent Manometric Studies for epiphrenic diverticula (to rule out motor disorder) No endoscopy (risk for perforation) No blind insertion of NG tube Management: Surgery 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 stenosis, hiatal hernia, or a motility disorder. • 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 Assessment and Diagnosis:  Ambulatory pH monitoring (gold standard) transnasal catheter placement or endoscopic wireless capsule placement for approximately 24 hours  Proton Pump Inhibitor (PPI) trial KK Management  Lifestyle modification (tobacco cessation, limiting alcohol, weight loss, elevating the head of the bed, avoiding eating before bed, and altering the diet)  Pharmacologic  Surgical (Nissen fundoplication - wrapping of a portion of the gastric fundus around the sphincter area of the esophagus) DIGESTIVE SYSTEM- MEDSURG PRELIM KK Medical Management - Antibiotics - Antidiarrheal - H2 Receptor Antagonists - Proton Pump Inhibitors - Prostaglandin E1 Analogue Nursing Management (Acute Gastritis): Barrett Esophagus  - A condition where the lining of the esophagus is altered and occurs in association with: Family history Esophageal adenocarcinoma (EAC) GERD Smoking Obesity *Patient complains of GERD symptoms and/or that of 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 Disorders of the Stomach Gastritis  Inflammation of the gastric mucosa which can be: - Acute (few hours to days) erosive – caused by local irritants (aspirin, NSAIDs, corticosteroids, alcohol, radiation therapy. A strong acid/alkali can cause gangrene, 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) - Promote optimal nutrition Allow the gastric mucosa to heal: NPO for few days, IV therapy, offer ice chips if symptoms subside, 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 DIGESTIVE SYSTEM- MEDSURG PRELIM KK DIGESTIVE SYSTEM- MEDSURG PRELIM KK