GASTROINTESTINAL SYSTEM

Gastrointestinal Assessment
Laboratory Procedures

COMMON LABORATORY PROCEDURES

FECALYSIS Examination of stool consistency, color and the presence of occult blood. Special tests for fat, nitrogen, parasites, ova, pathogens and others

COMMON LABORATORY PROCEDURES

FECALYSIS: Occult Blood Testing Instruct the patient to adhere to a 3-day meatless diet No intake of NSAIDS, aspirin and anti-coagulant Screening test for colonic cancer

COMMON LABORATORY PROCEDURES

Upper GIT study: barium swallow Examines the upper GI tract Barium sulfate is usually used as contrast

COMMON LABORATORY PROCEDURES

Upper GIT study: barium swallow Pre-test: NPO post-midnight Post-test: Laxative is ordered, increase pt fluid intake, instruct that stools will turn white, monitor for obstruction

COMMON LABORATORY PROCEDURES

Lower GIT study: barium enema Examines the lower GI tract Pre-test: Clear liquid diet and laxatives, NPO post-midnight, cleansing enema prior to the test

COMMON LABORATORY PROCEDURES

Lower GIT study: barium enema Post-test: Laxative is ordered, increase patient fluid intake, instruct that stools will turn white, monitor for obstruction

COMMON LABORATORY PROCEDURES

Gastric analysis Aspiration of gastric juice to measure pH, appearance, volume and contents Pre-test: NPO 8 hours, avoidance of stimulants, drugs and smoking Post-test: resume normal activities

COMMON LABORATORY PROCEDURES

EGD (esophagogastroduodenoscopy) Visualization of the upper GIT by endoscope Pre-test: ensure consent, NPO 8 hours, pre-medications like atropine and anxiolytics

COMMON LABORATORY PROCEDURES

EGD esophagogastroduodenoscopy Intra-test: position : LEFT lateral to facilitate salivary drainage and easy access

COMMON LABORATORY PROCEDURES

EGD (esophagogastroduodenoscopy) Post-test: NPO until gag reflex returns, place patient in SIMS position until he awakens, monitor for complications, saline gargles for mild oral discomfort

COMMON LABORATORY PROCEDURES

Lower GI- scopy Use of endoscope to visualize the anus, rectum, sigmoid and colon Pre-test: consent, NPO 8 hours, cleansing enema until return is clear

COMMON LABORATORY PROCEDURES

Lower GI- scopy Intra-test: position is LEFT lateral, right leg is bent and placed anteriorly Post-test: bed rest, monitor for complications like bleeding and perforation

COMMON LABORATORY PROCEDURES

Cholecystography Examination of the gallbladder to detect stones, its ability to concentrate, store and release the bile Pre-test: ensure consent, ask allergies to iodine, seafood and dyes; contrast medium is administered the night prior, NPO after contrast administration

COMMON LABORATORY PROCEDURES

Cholecystography Post-test: Advise that dysuria is common as the dye is excreted in the urine, resume normal activities

COMMON LABORATORY PROCEDURES

Paracentesis Removal of peritoneal fluid for analysis

COMMON LABORATORY PROCEDURES

Paracentesis Pre-test: ensure consent, instruct to VOID and empty bladder, measure abdominal girth

COMMON LABORATORY PROCEDURES

Paracentesis Intra-test: Upright on the edge of the bed, back supported and feet resting on a foot stool

COMMON LABORATORY PROCEDURES

Liver biopsy Pretest Consent NPO Check for the bleeding parameters

COMMON LABORATORY PROCEDURES

Liver biopsy Intratest

Position: Semi fowlers LEFT lateral to expose right side of abdomen

COMMON LABORATORY PROCEDURES

Liver biopsy Post-test: position on RIGHT lateral with pillow underneath, monitor VS and complications like bleeding, perforation. Instruct to avoid lifting objects for 1 week

The NURSING PROCESS in GIT Disorders

Assessment Health history Nursing History PE Laboratory procedures

The ABDOMINAL examination

The sequence to follow is: Inspection Auscultation Percussion Palpation

The GIT System: Anatomy and Physiology

The GIT is composed of two general parts The main GIT starts from the mouthEsophagusStomachSILI The accessory organs are the
Salivary glands Liver Gallbladder Pancreas

The GIT ANATOMY

The Mouth Contains the lips, cheeks, palate, tongue, teeth, salivary glands, masticatory/facial muscles and bones Anteriorly bounded by the lips Posteriorly bounded by the oropharynx

The GIT Physiology

The Mouth Important for the mechanical digestion of food The saliva contains SALIVARY AMYLASE or PTYALIN that starts the INITIAL digestion of carbohydrates

The GIT ANATOMY

The Esophagus A hollow collapsible tube Length- 10 inches Made up of stratified squamos epithelium

The GIT ANATOMY

The Esophagus The upper third contains skeletal muscles The middle third contains mixed skeletal and smooth muscles The lower third contains smooth muscles and the esophago-gastric/ cardiac sphincter is found here

The GIT PHYSIOLOGY

The Esophagus Functions to carry or propel foods from the oropharynx to the stomach Swallowing or deglutition is composed of three phases:

The GIT ANATOMY

The stomach J-shaped organ in the epigastrium Contains four parts- the fundus, the cardia, the body and the pylorus The cardiac sphincter prevents the reflux of the contents into the esophagus The pyloric sphincter regulates the rate of gastric emptying into the duodenum Capacity is 1,500 ml!

The GIT PHYSIOLOGY

The functions of the stomach are generally to digest the food (proteins) and to propel the digested materials into the SI for final digestion The Glands and cells in the stomach secrete digestive enzymes:

The GIT PHYSIOLOGY

Stomach: 1. Parietal cells- HCl acid and Intrinsic factor 2. Chief cells- pepsin digestion of PROTEINS to POLYPEPTIDES 3. Antral G-cells- gastrin INC HCL acid production 4. Mucus neck cells- mucus

The GIT ANATOMY

The Small intestine Grossly divided into the Duodenum, Jejunum and Ileum The duodenum contains the two openings for the bile and pancreatic ducts The ileum is the longest part (about 12 feet)

The GIT physiology

The intestinal glands secrete digestive enzymes that finalize the digestion of all foodstuff Enzymes for carbohydrates disaccharidases Enzymes for proteins dipeptidases and aminopeptidases Enzyme for lipids intestinal lipase

The GIT ANATOMY

The Large intestine Approximately 5 feet long, with parts: 1. The cecum widest diameter, prone to rupture 2. The appendix 3. The ascending colon 4. The transverse colon 5. The descending colon 6. The sigmoid most mobile, prone to twisting 7. The rectum

The GIT Physiology

Absorbs water Eliminates wastes Bacteria in the colon synthesize Vitamin K Appendix participates in the immune system

The GIT Physiology

SYMPATHETIC Generally INHIBITORY! Decreased gastric secretions Decreased GIT motility PARASYMPATHETIC Generally EXCITATORY! Increased gastric secretions Increased gastric motility

But: Increased sphincteric tone and constriction of blood vessels

But: Decreased sphincteric tone and dilation of blood vessels

ANATOMY AND PHYSIOLOGY

Upper alimentary canal Mouth Pharynx (throat) Esophagus Stomach 1st half of duodenum

GASTROESOPHAGEAL REFLUX DISEASE

-Excessive reflux of hydrochloric acid into the esophagus. Predisposing Factors: 1.Incompetent LES 2.Pyloric Stenosis 3.Other Esophageal disorder:

GASTROESOPHAGEAL REFLUX DISEASE

Signs and Symptoms: Pyrosis Dyspepsia Regurgitation Dysphagia Odynophagia Heart-attack like symptom

GASTROESOPHAGEAL REFLUX DISEASE

Diagnostics: EGD esophagogastroduodenoscopy 24 hr pH monitoring Esophagoscopy

GASTROESOPHAGEAL REFLUX DISEASE

Nursing Management: 1.Administer Medications as ordered 2.HT -Avoid irritants such as spicy or acidic foods, alcohol, caffeine, and tobacco. -avoid food or drink 2 hours before bedtime or laying down after eating. Elevate the head of the bed on 6-8in blocks 3. Assist in surgery. Nissen fundoplication -

PEPTIC ULCER DISEASE

Involves ulceration, circumscribed breaks in the mucosa, occurring in the duodenum (duodenal ulcer), the stomach (gastric ulcer), and less commonly, the distal esophagus and the jejunum.

PEPTIC ULCER DISEASE

Predisposing Factors: 1.Helicobacter Pylori 2.Hereditary 3.Psychological Factors (Stress, Anxiety, Type A) 4.Smoking and Alcohol use 5.Use of Ulcerogenic drugs 6.Increased intake of caffeine, soda, choco, tea 7.Irregular Diet 8.Zollinger Ellison Syndrome

PEPTIC ULCER DISEASE

PATHOLOGY

PEPTIC ULCER DISEASE

DUODENAL ULCER
Age 30-60 M:F 2:1 / 80% Duodenal Bulb Hypersecretion of HCL Wt Gain Pain is Burning, aching, gnawing in the right epigastrium; 2-3 hours p eating; relieved by eating. 12-3am Vomiting Uncommon Bleeding less likely; Melena Malignancy is rare Complications: Perforation

GASTRIC ULCER
Age 50 and above M:F 1:1 / 15% Antrum/ Pylorus Normal HCL Wt loss Pain is Burning, aching, gnawing in the upper epigastrium; 30 mins to 1 hour p eating;unrelieved by eating. Vomiting Common Bleeding more likely; Hematemesis Malignacy occurs occasionally Complications: G-CA, Hemorrhage

PEPTIC ULCER DISEASE

Diagnostics: Barium swallow shows an ulcerated area Endoscopy identifies the inflammatory changes, ulcers and lesions. Biopsy determines the presence of H. Pylori/ Urease test Gastric Analysis determines Normal/Increased gastric acid secretion Occult blood test

PEPTIC ULCER DISEASE

Nursing Management: Administer Medications as ordered: Give bland diet and small frequent meals (no hot/cold, meat, alcohol, caffeine, milk/products) Provide teaching on stress reduction and relaxation techniques Monitor for complications of PUD

PEPTIC ULCER DISEASE

Nursing Management: Assisst in Surgery 1.Vagotomy Severing of the vagus nerve. Decreases gastric acid by diminishing choinergic stimulation to the parietal cells, making them less responsive to gastrin. 2.Pyloroplasty a longitudinal incision is made into the pylorus and transversely sutured closed to enlarge outlet and relax the muscle.

PEPTIC ULCER DISEASE

ANTRECTOMY 1.Billroth 1 removal of the lower portion of the antrum of the stomach (which contains the cellls that secrete gastrin) as well as a small portion of the duodenum and pylorus. The remaining segment is anastomosed to the duodenum. (Gastroduodenuostomy) 2.Billroth 2 Lower portion of the antrum is anatomosed to the jejunum. (Gastrojejunostomy)

PEPTIC ULCER DISEASE

SURGICAL PROCEDURES FOR PUD Post-operative Nursing management 1. Monitor VS 2. Post-op position: FOWLERS 3. NPO until peristalsis returns 4. Monitor for bowel sounds 5. Assess surgical dressing

Conditions of the Stomach

Post-operative Nursing management 6. Monitor I and O, IVF 7. Maintain NGT 8. Diet progress: clear liquid full liquid six bland meals 9. Watch Out for Complication DUMPING SYNDROME

DUMPING SYNDROME
DUMPING SYNDROME A condition of rapid emptying of the gastric contents into the small intestine usually after a gastric surgery Symptoms occur 30 minutes after eating

COMMON GIT SYMPTOMS AND MANAGEMENT

PATHOPHYSIOLOGY Foods high in CHO and electrolytes must be diluted in the jejunum before absorption takes place.

COMMON GIT SYMPTOMS AND MANAGEMENT

PATHOPHYSIOLOGY The rapid influx of stomach contents will cause distention of the jejunum early symptoms

COMMON GIT SYMPTOMS AND MANAGEMENT

PATHOPHYSIOLOGY The hypertonic chyme will draw fluid from the blood vessels to dilute the high concentrations of CHO and electrolytes

COMMON GIT SYMPTOMS AND MANAGEMENT

Later, there is increased blood glucose stimulating the increased secretion of insulin Then, blood glucose will fall causing reactive hypoglycemia

COMMON GIT SYMPTOMS AND MANAGEMENT

DUMPING SYNDROME ASSESSMENT FINDINGS: early symptoms 1. Nausea and Vomiting 2. Abdominal fullness 3. Abdominal cramping 4. Palpitation 5. Diaphoresis

COMMON GIT SYMPTOMS AND MANAGEMENT

DUMPING SYNDROME ASSESSMENT FINDINGS: LATE symptoms: 6. Drowsiness 7. Weakness and Dizziness 8. Hypoglycemia

COMMON GIT SYMPTOMS AND MANAGEMENT DS NURSING INTERVENTIONS 1. Advise patient to eat LOWcarbohydrate HIGH-fat and HIGHprotein diet 2. Instruct to eat SMALL frequent meals, include MORE dry items. 3. Instruct to AVOID consuming FLUIDS with meals

COMMON GIT SYMPTOMS AND MANAGEMENT

DS NURSING INTERVENTIONS

4. Instruct to LIE DOWN after meals 5. Administer anti-spasmodic medications to delay gastric emptying

ANATOMY AND PHYSIOLOGY

II. Middle Alimentary canal Function: for absorption - Complete absorption large intestine 2nd half of duodenum Jejunum Ileum 1st half of ascending colon

APPENDICITIS
Appendicitis is inflammation of the vermiform appendix. Male>Females Ages 10 and 30 years Predisposing Factors (Obstruction):
a. b. c. d. Fecalith Kinking of appendix Inflammation Neoplasm

APPENDICITIS
Fecalith, Kinked appendix, inflammation, neoplasm Obstruction Increased Intraluminal Pressure Inflammatory response WBC Infiltration Edema Pus formation Necrosis Perforation Peritonitis

APPENDICITIS
Signs and Symptoms: Acute abdominal pain, RLQ Nausea and vomiting Low-grade fever Constipation or Diarrhea Board-like abdomen or abdominal rigidity if appendix ruptured.

APPENDICITIS
Diagnostics: CBC Leukocytosis UTZ reveals enlarged/inflammed appendix X-ray reveals enlarged appendix

CONDITIONS OF THE LARGE INTESTINE

NURSING INTERVENTIONS 1. Preoperative care NPO Consent Monitor for perforation and signs of shock

APPENDICITIS
Nursing Management: 1.Obtain VS 2.Assist in surgical procedure (appendectomy)

APPENDICITIS
NURSING INTERVENTIONS 1. Preoperative care Monitor bowel sounds, fever and hydration status POSITION of Comfort: RIGHT SIDELYING in a low FOWLERS Avoid Laxatives, enemas & HEAT APPLICATION

APPENDICITIS

2. Post-operative care Monitor VS and signs of surgical complications Maintain NPO until bowel function returns If rupture occurred, expect drains and IV antibiotics

APPENDICITIS

2. Post-operative care POSITION post-op: RIGHT sidelying, SEMI- FOWLERS to decrease tension on incision, and legs flexed to promote drainage Administer prescribed pain medications

PERITONITIS
Is acute or chronic inflammation of the peritoneum.

PERITONITIS
Predisposing Factors: 1.E. coli/ streptococcus faecalis infection of the peritoneum 2.Chemical irritation: ruptured appendix, bladder, bile spillage-gallbladder 3.Contamination of peritoneal cavity with surgical glove powder, particles from suture materials, lint from surgical drapes 4.Penetrating abdominal wound or bowel strangulation

PERITONITIS
PATHOLOGY

PERITONITIS
Signs and Symptoms: Severe localized or diffused abdominal pain Paralytic ileus produces abd distention Nausea and vomiting Bowel sounds are decreased or absent Fever, tachycardia, and chills >>> sepsis Shallow, guarded respirations suggest diaphragmatic involvement Signs of dehydration and acidosis are late

PERITONITIS
DIAGNOSTICS: CBC Leukocytosis Paracentesis identifies the causative organism X-ray reveals the location of the perforation

PERITONITIS
Nursing Management: Administer Medications Monitor respiratory status closely Minimize pain. Position the client to maximize comfort Maintain aseptic technique

ANATOMY AND PHYSIOLOGY

III. Lower Alimentary Canal Function: elimination 2nd half of ascending colon Transverse Descending colon Sigmoid Rectum

INTESTINAL OBSTRUCTION
Exists when blockage prevents the normal flow of intestinal contents through the intestinal tract. 2 Types 1.Mechanical Obstruction intraluminal obstruction fro pressure on the intestinal wall occurs. 2.Functional Obstruction the intestinal musculature cannot propel the contents along the bowel.

INTESTINAL OBSTRUCTION
MECHANICAL OBSTRUCTION: Adhesion loops of intestine become adherent to areas that heal slowly or scar after abdominal surgery. Intussusception one part of the intestine slips into another part located below it. Volvulus bowel twists and turns on itself. Hernia Protrusion of intestine through a weakened area in the abdominal muscle or wall.

INTESTINAL OBSTRUCTION
Small Bowel Obstruction Crampy abdominal pain that is wavelike and colicky Pass out blood and mucus but no feces or flatus Vomiting* Reverse peristaltic waves Dehydration (Thirst, drowsiness, weakness, dry mucous membranes) Abdominal Distention Large Bowel Obstruction Constipation Altered stool shape Weakness Weight Loss Anorexia Abdominal Distention Large bowel is visibly outlined in the abd wall Crampy lower abd pain Fecal Vomiting Dehydration

INTESTINAL OBSTRUCTION
Diagnostics: Abdominal Xray CT, and MRI reveals abnormal quantities of gas and/or fluid, distended intestine and site of obstruction. Laboratory studies reveals electrolye imbalances

INTESTINAL OBSTRUCTION
Nursing Management: 1. Maintain NGT decompression of the bowel 2. Assess NGT output 3. Monitor I&O strictly 4. Assess for Improvement: Return of bowel sounds, decreased abd distention, abd pain, and passage of flatus or stool. 5. Report to AP if there is discrepancies in I&O, worsening of pain and abd distention, & increased ngt output. 6. Assisst in Surgery

INTESTINAL OBSTRUCTION
Surgical Management: Surgical Mgt depends on the cause of intestinal obstruction. Ileostomy, Cecostomy, Colostomy Colonoscopy untwist and decompress the bowel. Surgical resection

DIVERTICULOSIS AND DIVERTICULITIS

Diverticulosis Abnormal out-pouching of the intestinal mucosa occurring in any part of the LI most commonly in the sigmoid Diverticulitis Inflammation of the diverticulosis

DIVERTICULOSIS
PATHOPHYSIOLOGY Increased intraluminal pressure, LOW volume in the lumen and Decreased muscle strength in the colon wall herniation of the colonic mucosa

DIVERTICULOSIS
ASSESSMENT findings for D/D 1. Left lower Quadrant pain 2. Flatulence 3. Bleeding per rectum 4. nausea and vomiting 5. Fever 6. Palpable, tender rectal mass

CONDITIONS OF THE LARGE INTESTINE

DIAGNOSTIC STUDIES 1. If no active inflammation, COLONOSCOPY and Barium Enema 2. CT scan is the procedure of choice! 3. Abdominal X-ray

CONDITIONS OF THE LARGE INTESTINE

NURSING INTERVENTIONS 1. Maintain NPO during acute phase 2. Provide bed rest 3. Administer antibiotics, analgesics like meperidine (morphine is not used) and antispasmodics 4. Monitor for potential complications like perforation, hemorrhage and fistula 5. Increase fluid intake

CONDITIONS OF THE LARGE INTESTINE

NURSING INTERVENTIONS 6. Avoid gas-forming foods or HIGH-roughage foods containing seeds, nuts to avoid trapping 7. introduce soft, high fiber foods ONLY after the inflammation subsides 8. Instruct to avoid activities that increase intra-abdominal pressure

CHRONIC INFLAMMATORY BOWEL DISEASE

REGIONAL ENTERITIS (Crohns Disease) - Is a subacute and chronic inflammation that extends through all layers of the bowel wall from the intestinal mucosa. ULCERATIVE COLITIS is an inflammatory disease of the submucosal layer of the colon and rectum characterized by continuously occuring ulcerations of intestinal epithelium.

CIBD
Cause: UNKNOWN Incidence Rate: Age 15&30; 50&70 M:F 1:1 Predisposing Factors: Hereditary/ Family History Pesticides, Food additives, Tobacco, Radiation Race: Caucasians and Jewish Heritage NSAIDs

CIBD
Crohns Disease Course is prolonged, variable Transmural thickening Location: Ileum, ascendingC Bleeding is unsual; if yes, tends to be mild. Perianal involvement is common Fistulas are common Rectal involvement 20% Diarrhea is less severe Ulcerative Colitis Exacerbations and remissions Mucosal Ulceration Rectum, descending colon Bleeding is common and severe Perianal involvement is rare-mild Fistulas are rare Rectal involvement 100% Diarrhea is severe

CIBD
ASSESSMENT findings for CD 1. Fever 2. Abdominal distention 3. Diarrhea 4. Colicky abdominal pain 5. Anorexia/N/V 6. Weight loss 7. Perianal fistulas and abscesses

CIBD
ASSESSMENT findings for UC 1. Anorexia 2. Weight loss 3. Fever 4. SEVERE diarrhea with Rectal bleeding, containing pus, and mucosa. 5. Anemia 6. Dehydration 7. Abdominal pain and cramping

CIBD
Diagnostics (CD): Barium study of upper GIT reveals string sign Barium enema shows ulceration and cobblestone appearance Colonoscopy reveals ulceration separated by normal mucosa

CIBD
Diagnostics (UC): Barium enema shows mucosal irregularities, shortening of the bowel and dilatation of bowel loops. Colonoscopy reveals friable mucosa with pseudopolyps or ulcers in the descending/sigmoid colon Stool analysis is positive for blood.

NURSING INTERVENTIONS for CD and UC

1. Maintain NPO during the active phase 2. Monitor for complications like severe bleeding, dehydration, electrolyte imbalance 3. Monitor bowel sounds, stool and blood studies 4. Restrict activities, promote intermittent rest and BR to minimize pain 5. Administer IVF, electrolytes and TPN if prescribed

NURSING INTERVENTIONS for CD and UC

6. Instruct the patient to AVOID gas-forming foods, MILK products and foods such as whole grains, nuts, RAW fruits and vegetables especially SPINACH, pepper, alcohol and caffeine 7. Diet progression- clear liquid LOW residue, high protein diet 8. Administer drugs 9. Assist in surgery

CIBD
Surgery: 1.Total colectomy with Ileostomy. 2.Total colectomy with continent ileostomy 3.Total colectomy with ileo-anal anastomosis

IRRITABLE BOWEL SYNDROME

Is a common functional disorder of gastrointestinal motility not associated with anatomic changes. Predisposing Factors: 1.Psychologic Stress 2.Pre-diverticular disease with changes in the bowel wall 3.Low-fiber diet/ high in stimulating/irritating food 4.Alcohol consumption and smoking

IRRITABLE BOWEL SYNDROME

TRIAD S & Sx: 1.Abdominal Pain 2.Altered bowel habits 3.Absence of detectable disease

IRRITABLE BOWEL SYNDROME

Diagnosis: Barium enema and colonoscopy reveals spasm, distention, or mucus accumulation in the intestine. CBC normal Stool analysis is normal

IRRITABLE BOWEL SYNDROME

Nursing Management: Administer Medications Teach the client on stress reduction and relaxation techniques Eat a well balanced diet, high-fiber diet, Adhere to a schedule of regular work and rest periods Drink six to eight glasses of h2o/day not with meals to prevent constipation

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