FUNCTIONS OF THE DIGESTIVE TRACT

-Breakdown of food for digestion

- Digestion: begins with the act of chewing, in which food is broken down into small particles that can be swallowed and mixed
with digestive enzymes
-Absorption into the bloodstream of small nutrient molecules produced by digestion
-Absorption: the major function of the small intestine. Vitamins and minerals absorbed are essentially unchanged. Absorption
begins in the jejunum and is accomplished by active transport and diffusion across the intestinal wall into the circulation
-Elimination of undigested unabsorbed foodstuffs and other waste products
-Elimination: occurs after digestion and absorption when waste products are eliminated from the body
-Enzymes and Secretions:
-Chewing and swallowing: saliva, salivary amylase
-Gastric function: hydrochloric acid, pepsin, intrinsic factor
-Small intestine: amylase, lipase, trypsin, bile

ASSESSMENT OF THE GI SYSTEM

-Health history:
-Information about abdominal pain, dyspepsia, gas, nausea and vomiting, diarrhea, constipation, fecal incontinence, jaundice,
and previous GI disease is obtained
-Pain: character, duration, pattern, frequency, location, distribution of referred abdominal pain, time of the pain; can vary greatly
depending on the underlying cause
-Dyspepsia: most common symptom of patients with GI dysfunction (indigestion)
-Intestinal gas: bloating, distention, or feeling “full of gas” with excessive flatulence as a symptom of food intolerance or gallbladder
disease
-Nausea and vomiting: nausea a vague, uncomfortable sensation of sickness or “queasiness” that may or may not be followed by
vomiting
-Change in bowel habits and stool characteristics:
-May signal colonic dysfunction or disease -Constipation, diarrhea
-Past health, family and social history
-Oral care and dental visits -Use of alcohol and tobacco
-Lesions in mouth -Dentures
-Discomfort with certain foods

PHYSICAL ASSESSEMENT OF THE GI SYSTEM

-oral cavity: lips, gums, tongue
-abdominal assessment: 4 quadrant method
-inspection, auscultation, percussion, palpation (I always perfect pals)
-rectal inspection
-Age-related changes:
-Mouth/Pharynx (Difficulty chewing and swallowing)
-Injury/loss or decay of teeth
-Atrophy of taste buds, ↓ Saliva production, Reduced ptyalin and amylase in saliva
-Esophagus (Reflux and heartburn):
-↓ Motility and emptying
-Weakened gag reflex
- ↓ Resting pressure of lower esophageal sphincter
-Stomach (Food intolerances, malabsorption, or ↓ vitamin B12 absorption)
-Degeneration and atrophy of gastric mucosal surfaces with ↓ production of HCl
-↓ Secretion of gastric acids and most digestive enzymes
-↓ Gastric motility and emptying
-Small Intestine (↓ Motility and transit time, which lead to complaints of indigestion and constipation)
-Atrophy of muscle and mucosal surfaces
 -Thinning of villi and epithelial cells
-Large Intestine (↓ Motility and transit time, which lead to complaints of indigestion and constipation↓ Absorption of nutrients
(dextrose, fats, calcium, and iron; Fecal incontinence)
-↓ Mucus secretion
- ↓ Elasticity of rectal wall
- ↓ Tone of internal anal sphincter
-Slower and duller nerve impulses in rectal area

DIAGNOSTIC TESTS
-Stool specimens
-Breath tests
-Abdominal ultrasonography (NPO 8-12 hrs pre test recommended to reduce gas)
-Endoscopic ultrasonography
-DNA testing
-Imaging studies: CT, PET, MRI, scintigraphy
-Upper GI tract study (contrast used, may be NPO)
-Lower GI tract study (contrast used, bowel prep, NPO)
-GI motility studies
-Endoscopic Procedures
-Manometry and electrophysiologic studies: measures the strength and muscle coordination of your esophagus when you swallow

DIGESTIVE DISORDERS W/ GENETIC COMPONENT

-Cleft lip and/or palate
-Familial adenomatous polyposis: cancer of the large intestine (colon ) and rectum
-Hereditary nonpolyposis colorectal cancer: increases the risk of many types of cancer
-Hirschsprung disease (a ganglionic megacolon)
-Inflammatory bowel disease (e.g., Crohn’s disease): broad term that describes conditions characterized by chronic inflammation of
the gastrointestinal tract
-Pyloric stenosis: condition in infants that blocks food from entering the small intestine

GENERAL NSG INTERVENTIONS FOR GI DIAGNOSTIC TESTS

-Provide:
-needed information about the test and the activities required
-instructions about post procedure care and activity restrictions
-health information and procedural education to patients and significant others
-Help the patient cope with discomfort and alleviate anxiety
-Inform the primary provider of known medical conditions or abnormal laboratory values that may affect the procedure
-Assess for adequate hydration before, during, and immediately after the procedure, and provide education about maintenance of
hydration
-Informed consent
-Prophylactic antibiotics
-Allergies (to contrast, shellfish, iodine; premedicate with Benadryl, corticosteroid)
-Renal function (creatinine level) ; kidney protection with IV sodium bicarbonate, oral acetylcysteine (Mucomyst)
-Pregnancy
-NPO (diabetic client concerns)
-Dehydration (encourage fluids post procedures to help eliminate barium)
-Metal removed, foil-backed skin patches removed pre-MRI
-Sedation (NPO, premed, assess gag reflex, O2 sat, LOC)
-Complications: (bleeding, perforation, infection, allergic reaction)

MANAGEMENT OF PATIENTS W/ GASTRIC AND DUODENAL DISORDERS

GASTRITIS
-inflammation of the stomach
-acute: happens rapidly, rapid onset, usually caused by dietary issues (eating foods that irritate the stomach lining) can be caused by
meds, alcohol, bile, stomach acid, radiation (anything that irritates the stomach lining)
-ingestion of strong acids (hydrochloric acid or nitric acid)
-ingestion of alkylating agents, bases that neutralize the stomach acid and bile, preventing it from working will also irritate the
stomach
-chronic: much more long term due to prolong inflammation of the lining, is usually related to malignant ulcer or H. pylori
-can be associated with autoimmune disease
-dietary factors like smoking and alcohol] but 9/10 will always be related to H. pylori
-chronic gastritis is usually nonerosive bc both are related to H. pylori
-erosive gastritis: eats out at the stomach lining, can cause holes (NSAIDs, alcohol, radiation)
-nonerosive gastritis: red irritation and inflammation (H. pylori)

MANIFESTATIONS OF GASTRITIS
-Diagnosis: xrays, endoscopy (upper GI system), biopsy
-acute: abdominal discomfort, headache, N&V, hiccups, lack of energy
-chronic: epigastric discomfort, esophageal area bc the acidity travels up from stomach to esophagus, anorexia (stop eating bc its
painful), heartburn after eating, excessive belching, sour taste in their mouth, N&V, intolerance to some foods, vitamin B deficiency bc
they stop eating (spicy, carbonated, acidic)] whatever causes more irritation
-erosive gastritis: bleeding bc stomach lining deteriorates, dark starry stool (bleeding at the stomach takes time to come out so the
blood turns old), coffee ground emesis, acute abdominal pain
-nonerosive gastritis: indigestion

MEDICAL MANAGEMENT
-acute: if set off by foods (eliminate those foods from your diet, esp alcohol)
-if set off by strong acid or alkylating base, will need a neutralizing agent, must avoid throwing up (will make it worse if
occurs)
-provide with things that will sooth, nutritional support, IV fluids, pain meds
-chronic: modify diet, promoting rest and reducing stress (can further exacerbate the issue)
-avoid alcohol, stop using NSAIDs
-BOTH: histamine antagonist (famotidine), proton pump inhibitors (omeprazole), prostaglandins, antiulcer/mucosal barriers (coats the
stomach lining, sucralfate) will decrease irritation
-antibiotics to treat H. pylori

PEPTIC ULCER DISEASE (PUD)

-related to erosion of the mucous membrane, forms excavation in the stomach (pylorus, duodenum or the esophagus)
-usually associated with H. pylori
-erosive gastritis can lead to a peptic ulcer
-risk factors: excess secretion of stomach acid (cont irritates the lining causing an ulcer), dietary factors (hot/spicy foods), chronic use
of NSAIDs, alcohol, smoking, family history
-manifestations: dull/gnawing pain, burning in midepigastric area, dyspepsia (heartburn), N&V, bloating
-treatment: meds (same as above), lifestyle changes (change diet, no NSAIDs/spicy foods, stop smoking), occasionally will have
surgery
-NSG: assess the pain and the methods they usually use to relieve pain, abdominal assessment, figure out lifestyle changes that need
to be made, educate about NSAIDs (most common ibuprofen, don’t use for everything), teach about s/s of anemia and bleeding (old
and new blood)

SURGICAL INTERVENTIONS
-vagotomy: clip the vagus nerve to decrease production of gastric acid, can be done open or laparoscopically
-pyloroplasty: drainage type procedure to assist with gastric emptying (pt is not emptying stomach fast enough, creates issues w/ a
peptic ulcer irritating the stomach lining)
-antrectomy: remove the lower portion of the stomach containing cells that secrete gastrin and remove small portion of the duodenum
to reconstruct (decreased acid production and faster emptying of the stomach)

MANAGEMENT OF POTENTIAL 3 COMPLICATIONS

1. management of hemorrhage: bleeding in the stomach, decreased cardiac output and death
-assess for s/s of bleeding, old or new blood in emesis
-assess for s/s of shock (tachycardia, hypotension, pallor)
-treatment: fluids and NG tube to suction, oxygen, address vitals (vasopressors to constrict vessels and increase BP, slow
down HR/ get tachycardia under control)
-control bleeding by endoscopic coagulation or open surgical intervention
2. pyloric obstruction: bottom part of the stomach constricts/blocks food from getting through (can't travel and sits in the stomach)
-s/s: N&V, constipation, epigastric fullness, turns into anorexia (feel so full don’t want to eat), overtime develop weightloss
-intervention: NG tube to decompress the stomach and suction, promote IV fluids and electrolytes, for the actual obstruction
can do balloon dilation (endoscopically inflate/deflate) if doesn’t work will need surgery
3. management of perforation/penetration: blood leaks out bc ulcer creates a hole in the lining, stomach contents leak out into the
sterile abdominal cavity
-s/s: severe and sudden upper abdominal pain, rigid abdomen (hard as a rock), develop pain that goes up their shoulder,
vomiting, s/s of shock bc they’re bleeding and bacteria is escaping into the abdomen
-treatment: immediate surgery to patch the perforation (otherwise death)

-Proton pump inhibitors: control gastric acid

-best to take 30 minutes b/f a meal
-are usually delayed release, need time to work
MANAGEMENT OF PTS W/INTESTINALA AND RECTAL DISORDERS

-CNS disorders: stroke, dementia, related to radiation ] a lot of reasons why pts are unable to control or have frequent liquid stools
-want to prevent deterioration of the skin
-Fecal incontinence: inflate a balloon to keep in place

ASSESSMENT AND DIAGNOSTIC FINDINGS (pts w/ intestinal and rectal disorders)

-history to determine etiology
-rectal examination
-endoscopic examinations
-radiography studies: xrays, CT, MRI
-barium enema: so we can see what else is going on inside the intestines
-anorectal manometry
-bowel schedule: every 2 hours ask them if they need to go, try anyway to get them used to it
-getting on a schedule will help with the incontinence

IRRITABEL BOWEL SYNDROME (IBS) don’t confuse with IBD (inflammation and destruction)
-causes: disorder of the GI tract, chronic functional disorder, recurrent abdominal pain that is associated disordered bowel mvmts,
diarrhea, constipation ] or both
-environmental factors: dairy products, caffeinated beverages, infectious agents
-immunologic, pts who have cytokine genes (proinflammatory), tumor necrosis factor (genetic)
-risk factors: chronic stress, sleep deprivation, surgery, infection, certain foods, diverticulitis, being women, eating large meals with
high content of fat
-signs and symptoms: alteration in bowel patterns, diarrhea, constipation or BOTH, complain of pain and bloating
-treatment: avoid triggers, treating symptoms (antidiarrheals, laxatives for constipation), decrease stress, avoid alcohol and smoking,
adequate fluid intake
 -MUST have a food diary to figure out triggers, track bowel patterns, stay away from triggers,

ASSESSMENT AND DIAGNOSTIC FINDINGS

-stool studies -colonoscopy
-contract radiography studies -manometry
-proctoscopy -electromyography
-barium enema -etc

DIVERTICULAR DISEASE
-diverticulum: intestines develop sacs, becomes a problem when they get infected
-can develop with no issues as long as the diet is good
-risk increases with age and is associated with low fiber diet
-diagnosed with a colonoscopy
-diverticulosis: developing the sacs/hernia sacks, no problem
-diverticulitis: food gets stuck in the sacs get inflamed/infection/flair up of diverticulosis]when it becomes a problem
-causes: food, bacteria or fecal matter getting stuck in the sacs
-can cause perforations, expand as they get inflamed and pop releasing intestinal content into the abdominal activity
-develop peritonitis or surgical abdomen
-s/s: pain, N&V, fever, tachycardia, chills, blood in stool
-tx: antibiotics (cipro, flagyl)
-NSG: inc fluid intake, soft foods, inc fiber (cooked vegetables), individualized exercise plan, bulk laxatives (make stool
bigger/more formed), stool softeners (softer/travels easier)

APPENDICITIS (most common reason for emergent abdominal surgery/surgical abdomen)

-causes: food gets stuck in the appendix area causing an infection
-s/s: pain in mid/right lower abdomen, describe pain as “dull, sharp, mild, severe”, if pain stops suddenly (perforation), fever, chills,
loss of appetite, diarrhea, N&V
-Rovsing’s sign: pain is felt in the opposite aside when pressed down
-tx: surgery, appendectomy, laparoscopy, meds (antibiotics, penicillin)
-NSG: assess for bleeding, relieve anxiety/pain, prevent atelectasis

INFLAMMATORY BOWEL DISEASE (IBD)

-related to inflammation (and IBS is more GI issue/disorder)
-characterized by 2 disease:
-Crohn’s disease: subacute and chronic inflammation of the GI tract (extends through all 3 layers of the intestines)
-periods of remission and exacerbation
-Ulcerative colitis: affects the superficial area of the intestine (multiple ulcerations and inflammation)
-mucosa becomes inflamed
-disease usually begins at the rectum and travels up and engulfs the entire colon

Clinical Manifestation Chron’s Disease Ulcerative Colitis

Location Ileum, ascending colon Rectum, descending colon
Bleeding Usually not, but if it occurs it tends to be Common-severe (bc it involves the
mild superficial area, “paper cuts”)
Perianal involvement Common Rare-mild
Fistulas Common (holes develop, bc involves all 3 Rare
layers)
Rectal involvement About 20% Almost 100% (bc that’s where it starts)
Diarrhea Less severe Severe
Abdominal mass Common (due to location) Rare
 Therapeutic management Corticosteroids, aminosalicylates Corticosteroids, aminosalicylates
Ostomies depend on how bad it gets (sulfasalazine (Azulfidine) (sulfasalazine) useful in preventing
Antibiotics recurrence
Parenteral nutrition Bulk hydrophilic agents
Partial or complete colectomy w/ Antibiotics
ileostomy or anastomosis Proctocolectomy w/ ileostomy
Rectum can be preserved in some pts Rectum can be preserved in only a few
Recurrence common pts “cured” by colectomy
Systemic complications Small bowel obstruction (small intestine, Toxic megacolon (only in the large
severe inflammation) intestine, nothing can get through)
Right-sided hydronephrosis/ Perforations Perforation
Nephrolithiasis Nephrolithiasis
Cholelithiasis (gall stones) Hemorrhage (can bleed out)
Arthritis Arthritis, pyelonephritis
Retinitis, iritis Retinitis, iritis, erythema nodosum
Erythema nodosum Cholangiocarcinoma
Malignant neoplasms

ACUTE ABDOMEN (peritonitis/surgical abdomen)

-hole somewhere, preformation occurred, GI contents are now escaping into the abdominal cavity
-sudden and severe abdominal pain, stomach is “angry” and rigid (hard as a rock), need immediate surgery
-causes
-manifestations: s/s of shock (hypotension, tachycardia), fever, chills, pain
-management: surgery, fluids, NG tube, oxygen, antibiotics