CARE OF PATIENTS WITH G.I.

DISORDERS o Milk is curdled and casein is set free

through the action of rennin.
Anatomy and Physiology
o Digestion of emulsified fats also
 Mouth starts in the stomach due to the
- Where digestion starts presence of small amounts of
- Mechanical digestion occurs through gastric lipase.
mastication (chewing)  Protection: acid medium is responsible for
- Chemical digestion occurs through the the reduced activity of harmful bacteria that
action of salivary amylase (ptyalin), which may have been taken in with food. It also
breakdown starches to maltose provides favorable medium for the
- Deglutition (swallowing) occurs once the absorption of calcium and other minerals.
food is broken down into small pieces and  Absorption: Mineral water, alcohol, glucose,
well mixed with saliva (food bolus). and some drugs are absorbed through the
 Esophagus gastric mucosa
- Serves as a passage for food bolus from  Controls passage of chyme into duodenum
mouth to stomach by peristalsis through peristaltic waves
- Distal end is guarded by lower esophageal  Carbohydrates are emptied within 1-2 hrs;
sphincter (LES) also known as cardiac proteins within 3-4 hrs; fats within 4-6 hrs.
sphincter (prevents gastric reflux) Once acidic chyme is formed, slow
 Stomach peristaltic waves travel from the fundus to
the pylorus. Pressure builds and pyloric
sphincter opens.
 Small Intestine

- Located in the left upper quadrant of the

abdomen
- Has an approximate capacity of 1,500 mls
- Following regions: cardiac region, fundus, - About 6 meters (20 – 22 ft) and extends
body, and antrum or pyloric region. from the pyloric sphincter to the ileocecal
- Functions: valve.
 Mechanical Digestion: storage, mixing and - Divided into three parts: duodenum,
liquefaction of food bolus into a chyme jejunum, ileum
 Secretion: 1,500 – 3,000 mls of gastric juice - Majority of the digestive process is
is secreted by the glands in the gastric completed in the duodenum.
mucosa. Gastric juice is composed of - Absorption of foods occur primarily in the
mucus, HCl, pepsinogen, and water. Gastrin small intestine
(hormone) is secreted directly into the - Functions:
bloodstream  Mucus secretion: Goblet cells and duodenal
 Chemical Digestion: digestion of proteins (Brunner’s) glands secrete mucus to protect
starts in the stomach through the action of the mucosa
pepsin, which converts protein into  Secretion of enzyme:
polypeptides. o Brush border cells secrete sucrase,
o Amylase from the salivary glands is maltase and enterokinase which act
inactivated by the acidity in the on disaccharides (carbohydrates)
stomach so carbohydrate digestion o Peptidase acts on polypeptides
stops. (protein)
o Pepsinogen (inactive enzyme) o Enterokinase activates trypsinogen
converted into pepsin (active form) from the pancreas
in the presence of HCl  Secretion of hormones: Endocrine cells
secrete cholecystokinin, secretin, and
 enterogastrone that regulate the secretion of - Colon is divided into: ascending, transverse,
bile, pancreatic juice, and gastric juice. descending, and sigmoid sections
 Chemical digestion: In the presence of - Final segments are the rectum and anus
acidic chyme in the duodenum the following - Functions:
will occur:  Motor activities: haustral churning and
1. Presence of carbohydrates, fats, peristalsis
and protein stimulate secretion of  Secretion: mucus protects the mucosa from
pancreozymin. This enzyme injury, fecal particles into a formed mass,
stimulates enzyme secretion of lubricates and allows passage of fecal
pancreatic amylase, lipase and residue and counteracts the effects of acid-
trypsin. forming bacteria.
 Amylase completes  Absorption of water, Na, and Cl.
digestion of carbohydrates; Approximately 800-1000 mls of water is
lipase completes digestion absorbed in the large intestine
of fats; trypsin completes  Vitamin synthesis: colonic bacterial flora
digestion of protein synthesizes vitamin K, thiamine, riboflavin,
2. Presence of fats in the acidic Vit. B12, folic acid, biotin, and nicotinic acid.
chyme, duodenum secretes  Formation of feces: fecal material is ¾ water
cholecystokinin which causes and ¼ solid material
contraction of the gallbladder,  Defecation: Act of expelling feces from the
relaxation of sphincter of Oddi, body.
thereby releasing bile
Physiologic Changes in the GI System with Aging
 Bile emulsifies fats, thereby
enabling pancreatic lipase 1. Teethe may become loose from loss of
to complete digestion of fats supporting gums and bone.
 Bile and pancreatic juice are 2. Aging teeth may darken, become uneven and
alkaline, they neutralize the fracture. This is due to reduced circulation in the
acidic chyme gums.
 Absorption: Nutrient and water move from 3. Dryness of mucous membranes and increased
the lumen of the small intestine into the susceptibility to breakdown. Due to decreased
blood capillaries and lacteals in the villi. output of salivary glands. This decrease can
Absorption is by active transport, by cause difficulty swallowing and decreased
osmosis, and by diffusion. stimulation of taste buds.
 Motor activities: Mixing (segmental) 4. Secretion of digestive enzymes and bile also
movement and peristalsis propel the chyme decreases.
through the small intestine. The chyme  In the stomach, atrophy of gastric mucosa leads
remains in the small intestine for 3-10 hrs. to a decreased secretion of HCl. A decrease in
The residue moves in the large intestine. HCl causes reduction in iron and Vit B12
 Large Intestine absorption and a proliferation of bacteria.
Reduction leads to development of anemia.
Increased bacteria in the gut may result in
diarrhea and infection.
 Decrease in bile secretion, absorption of fats
and fat-soluble vitamins becomes impaired.
Decreased absorption of fats can lead to weight
loss and decreased absorption in fat-soluble
vitamins can lead to various problems such as
- Extends from the ileocecal valve to the
altered calcium metabolism and bleeding from
anus. Approximately 1.5 meters (5-6 ft) long.
the decrease of Vit. K. Vit. K is needed to
- Divided into the following parts: cecum,
synthesize prothrombin.
colon, rectum, anus
- Vermiform appendix is attached to the Assessment of Clients with GI Disorders
cecum
 History
 Demographic data, religion, personal and family o Pharynx – tonsil abnormalities,
history: lesions, ulcers, uvular deviation,
 General health status unusual mouth odor
 Previous GI disorders and surgery  Palpation: lips, gingival, buccal, mucosa,
 Change in bowel habits and, GI tongue
bleeding, jaundice, weight loss o Area is checked for masses,
 Long term use of laxatives swelling, tenderness
 Family history of GI disorders  Assessing the Abdomen
 Diet History  Position – Supine with knees flexed
 Usual foods and fluids that are typically (Dorsal recumbent postiton)
consumed  IAPePa: Inspection, Auscultation,
 Quality and quantity of foods ingested Percussion, Palpation
 Relationship of food intake and GI Note: Auscultation is performed before
symptoms percussion and palpation because
 Usual and current appetite percussion and palpation can increase
 Symptoms such as nausea and intestinal activity and alter bowel
vomiting, difficulty of swallowing sounds. No abdominal palpation is done
 Chief Complaint in pt with tumor of the liver or kidney to
 Onset prevent rupture of tumor and massive
 Duration internal hemorrhage.
 Quality and characteristics o Inspection
 Severity  Abdomen – condition of
 Location the skin, contour
 Precipitating Factors  Skin should be
 Reliving factors smooth, intact
 Associated symptoms  Contour of the
 Medical History abdomen is flat,
 Major illness and hospitalizations concave,
 Use of medications rounded or
 Allergies to foods and other substances distended
 Family History depending on
 History of cancer, ulcers, colitis, the pt’s body
hepatitis, obesity type
 Psychosocial History and Lifestyle  Inspect umbilicus –
 Occupation – meal times and travel shape, position, color
 Social (concave, located at
o Stress – provoking situations midline, same color as
o Alcohol and nicotine the abdominal skin)
 Physical Examination  Note abdominal
 Assessing the Oral Cavity movements, pulsations,
 Inspection peristaltic movement.
o Lips – for abnormal color, Normally, peristaltic
lesions, nodules, symmetry movements are not
o Oral mucosa – redness, pallor, visible.
swelling, ulcers or leukoplakia  Auscultation
o Gums – redness, pallor, ulcers, o Bowel sounds (5 to 35/ minute)
bleeding rapid, high pitched, loud bowel
o Teeth – dental caries, dentures, sounds are hyperactive (e.g. in
missing/broken teeth gastroenteritis). Hypoactive
o Tongue – color, ulcers, bowel sounds occur at a rate of
abnormal coating, swelling or one every minute or longer
deviation to one side, movement (paralytic ileus) or after bowel
surgery.
 o Note: empty the bladder before  CEA (Carcinoembryonic Antigen)
auscultation of the abdomen,  (+) in colorectal Ca
because a full bladder can  Avoid Heparin for 2 days
interfere with sounds.  Specimen is obtained by venipuncture
Auscultation of bowel sounds is  D – Xylose Absorption Test
no longer recommended to  Initial blood/urine specimen are
assess for return of peristalsis in collected
postoperative patients.  NPO for 112 hrs
 Percussion  Blood/urine levels are measured
o To determine the size and  Done for diagnosis of malabsorption
location of abdominal organs  Exfoliative Cytology
and to detect fluid, air and  Done to detect malignant cells
masses.  Written consent is obtained
o Percussion sounds over  Liquid diet is given
abdomen:  Upper GI: Ngt insertion is done
 Tympanic high pitched,  Lower GI: laxative the night before and
loud, musical over air enema in the morning
 Dull-thud- like sound  Cells are obtained from saline lavage –
over fluid or solid via NGT for UGI / via proctoscope for
organs LGI
 Note: Avoid abdominal  Fecal Analysis
percussion in clients  Stool for Occult Blood (Guaiac Stool
with suspected Exam)
abdominal aneurysms o Done to detect G.I. bleeding
and in those clients with o Provide high fiber diet for 48-72
abdominal organ hours
transplants. o No red meats, poultry, fish,
 Palpation turnips, horseradish, cauliflower,
o Palpate abdomen by lightly broccoli, and melon. Red meats,
depressing (1-2 cm) the poultry, fish contain hemoglobin
abdomen in quadrant-to- fibers which may be mistaken
quadrant manner. as blood Turnips, horseradish,
o Assess for masses, rebound cauliflower, broccoli, and melon
tenderness, abdominal rigidity. are high in peroxidase and will
o Deep abdominal palpation cause false positive result. (The
should be performed cautiously reagent used for the test is
only by a skilled nurse hydrogen peroxide).
 Anthropometric Measure o Vitamin C causes false negative
1. Height and Weight reading.
2. Body Mass Index (BMI) o Done by placing hydrogen
BMI= Weight in kg. / Height (m2) peroxide to the stool specimen.
3. Circumferential Measurements If blue ring is formed, this
 Midarm muscle circumference (MAMC) indicates bleeding.
 Waist – to – hip proportions (greater o Withold for 48 hours: Iron,
than 0.8 in women and 1.0 for men Steroids, Indomethacin,
indicate fat distribution that is associated Colchicine
with negative health outcomes.  Iron causes blackish /
 Body Mass Index (BMI) greenish discoloration
of stool. This may be
18.5 – 24.9 Normal
mistaken as bleeding.
25 – 29.9 Overweight
This causes false
30 and above Obese
Diagnostic Tests positive result,
 Steroids, Indomethacin,
 Laboratory Tests Colchicine may cause
 Gl bleeding. These  Scout Film / Flat Plate of the Abdomen
medications may cause  Plain X-ray of the abdomen
false positive result.  Avoid belts or jewelries. Metals are
o 3 stool specimen will be radiopaque
collected (3 successful days)  UGIS (Upper GI Series / Barium Swallow)
 Stool for Ova and Parasites  To visualize the esophagus, stomach
o Send fresh, warm stool duodenum, and jejunum
specimen, especially if the  NPO 6-8 hrs
purpose of the test is to detect  Barium Sulfate (BaSO4) by mouth is
amoebiasis. administered. BaSO4 is a white, chalky
 Stool Culture substance
o Use sterile test tube and cotton  X-rays are taken on standing, lying
– tipped applicator to collect position
specimen. This ensures that the  After the procedure:
specimen is not contaminated. o Laxative is administered.
 Stool for Lipids BaSO4 causes constipation
o Done to assess steatorrhea o Increase fluid intake to prevent
o Include fats in the diet to assess constipation.
ability of GI to metabolize fats o Inform client that stools are
o Avoid alcohol for 3 days. Alcohol white for 24-72 hrs due to the
mobilizes fats and this will evacuation of BaSO4
cause false positive result. o Observe for Barium impaction
o 72-hour stool is collected. Store manifestations; distended
specimen on ice. abdomen, constipation
o Avoid mineral oil, neomycin SO4  LGIS (Lower GI Series / Barium Enema)
and other oily medications.  To visualize the colon
 Gastric Analysis  Low residue/clear liquid diet for 2 days
 Measures secretion of HCl and pepsin  Laxative for cleansing the bowel
 NPO for 12 hrs  Suppository/cleansing enema in A.M
 NGT is inserted, connected to the  BaSO4 is administered per rectum
suction  Care after the procedure – same as
 Gastric contents are collected every 15 UGIS
mins – 1 hr  Computed Tomography
 Uses beam of radiation to assess cross
HCl: Zollinger – Ellison sections of the body
Syndrome  Clear liquid diet in the morning
 If the procedure is done with contrast
Duodenal ulcer
medium
HCl: Gastric Ca o NPO 2-4 hrs
o Assess hx of allergy to seafoods
Pernicious Anemia
and iodine
 Inform pt that the procedure is painless
 Bernstein Test  Assess for claustrophobia
 To assess if chest pain is related to  Advise pt to remain still during the entire
gastro-esophageal reflux procedure
 NPO 6-8 hrs  Endoscopy
 NGT insertion  Upper GI Endoscopy
 Alternate instillation of NSS and 0.1%  Direct visualization of esophagus,
HCl stomach, and duodenum
 If no pain is experienced (-) for GER; if  Obtain written consent
pain is experienced (+) GER  NPO 6-8 hours
 Antacid is administered after the  Administer anticholinergic (e.g., AtSO4)
procedure to relieve discomfort. as ordered. To reduce mucus secretions
 Radiographic Tests and prevent aspiration.
  Sedatives, narcotics, tranquilizers. To  Hot Sitz bath to relieve
relax the client. discomfort in the
o E.g. Diazepam, Meperidine HCl anorectal area.
 Remove dentures, bridges. To prevent  Colonoscopy
airway obstruction. o Preparation of the client is same
 Local spray anesthetic (Lidocaine) on as in proctosigmoidoscopy.
posterior pharynx is administered to o Sedation is done to relax the
depress the gag reflex. Instruct the client client.
not to swallow saliva. For maximum o Position during the procedure:
effect of the anesthetic. Lidocaine is left side, knees flexed.
unpalatable. o After the procedure:
 After the procedure:  Monitor VS (note for
o Place the client in side lying vasovagal response,
position. To prevent aspiration. e.g. bradycardia,
o NPO until gag reflex returns (2-4 hypotension)
hrs).  Assess for signs and
o NSS gargle; throat lozenges. To symptoms of
soothe the throat. perforation.
o Monitor VS  Ultrasonography of the abdomen
o Assess: bleeding, crepitus o NPO 8-12 hrs
(neck), fever, neck / throat pain, o Laxative as ordered (to reduce
dyspnea, dysphagia, back / bowel gas)
shoulder pain  MRI (Magnetic Resonance Imaging)
o Advise to avoid driving for 12 o Produces cross – sectional
hours if sedative was used. images of organs by using
 Lower GI Endoscopy magnetic fields.
 Proctosigmoidoscopy (sigmoid, rectum) o NPO for 6-8 hours.
o Clear liquid diet 24 hours before o Instruct to remain still during the
the procedure. procedure.
o Administer cathartic / laxative as o Inform that procedure may last
ordered. for 60-90 minutes.
o Cleansing enema. o Remove jewelries/metals.
o Intestinal evacuant like GoLytely o Contraindications:
may be administered in place of  Pacemakers
enema. Instruct client to take  Aneurysm slips
240 cc every 10 minutes up to 2  Orthopedic screws
hours. It is expected that the
client will have watery stools Related Nursing Procedures for GI System
(diarrhea). 1. Gastric and Intestinal Decompression.
o Place the client in knee chest / 2. Esophageal Balloon Tamponade
lateral position during the 3. Enteral Feeding
procedure. This may be nasogastric tube feeding or
o Assess the signs of vasovagal gastrostomy feeding.
stimulation. The Gl tract is 4. Total Parenteral Nutrition (TPN)
supplied by the Vagus nerves. 5. Administering Enemas
o After the procedure: I. Management of Patients with Malnutrition
 Supine position for few  Malnutrition
minutes. To prevent  Malnutrition occurs when nutrient availability is
postural hypotension. inadequate or excessive (undernutrition and
 Assess for signs of overnutrition) over an extended period. It
perforation Bleeding, involves both starvation and obesity.
Pain, and Fever.  The two types of starvation are as follows:
 1. Primary malnutrition occurs when Enriched or neuropathic
adequate nutrition is not delivered to whole grain mental
upper Gl tract over an extended cereals and confusion
period (e.g famine, anorexia, bread Heart Failure
Edema
mechanical obstructions of the Gl
Vitamin B6 Yeast Sore,
tract, fad diets). (Pyridoxine) Wheat reddened
2. Secondary malnutrition occurs when germs tongue
the upper Gl tract fails to absorb, Pork Seborrhea –
metabolize, or use nutrients (e.g., Liver like dermatitis
ischemic bowel or Crohn's disease) Whole grain Paresthesia
 The different types of malnutrition associated cereals
Legumes
with protein and calorie deficits are as follows:
Vitamin B12 Beef Sore,
1. Kwashiorkor (Cobalamin) Fish reddened
 Inadequate protein intake with Silk tongue
adequate calorie intake Eggs Atrophy of
 Body weight at or above ideal Cheese the tongue
weight Megaloblastic
 Edema sometimes present. anemias
Paresthesia
 Visceral proteins (albumin,
Vitamin C Oranges Gingivitis
prealbumin, transferrin) below (Ascorbic Lemons Dry mouth
normal. Acid) Strawberries Alopecia
2. Marasmus Tomatoes Pruritus
 Inadequate calorie and protein Cabbage Ecchymotic
intake. Green lesions on the
 Cachectic appearance. peppers skin
Calcium Dairy Osteoporosis
 Body weight and anthropometric
products Osteomalacia
measurements (height, weight, Sardines
frame size, body mass index, Salmon
mid-arm muscle circumference Pork
(MAMC), waist normal to hip Green, leafy
proportions) below vegetables
 Visceral proteins within normal Copper Organ Decreased
meats absorption of
range.
Legumes iron
3. Mixed Chocolate Anemia
 Inadequate calorie and protein Nuts Neutropenia
intake with increased nutritional Leukopenia
requirements Vitamin D Fish and fish Softening of
 Cachectic appearance. (Calciferol) oil the bones
 Body weight and anthropometric Fortified Joint pain
dairy Fatigue
measurements below normal.
products Muscle
 Visceral proteins below normal. Tetany
 Sources of Micronutrients and Evidence of Vitamin E Sunflower, Lipid
Deficiency (Tocopherol) corn or absorption or
soybean oil transport
Micronutrient Sources Evidences of Wheat germ abnormalities
Deficit oils
Vitamin A Dark green, Loss of Folate (Folic Legumes Sore,
leafy or appetite and Acid) Liver reddened
yellow taste, Dark green tongue and
orange Night or leafy mouth
vegetables, Blindness, vegetables Glossitis
Milk fat, Egg Bumpy or Lean beef Megaloblastic
yolk scaly skin Potatoes Anemia
Vitamin B1 Lean meats Paresthesia Iodine Seafood Enlargement
(Thiamine) Egg yolk and Iodized salt of the thyroid
Legumes peripheral gland
 Iron Organ Hypochromic, 1. Obesity: Characterized by an excess
Meats microcytic accumulation of fats
Shellfish anemia : reflects an overall imbalance between
Poultry energy intake and expenditure
Legumes
 It increases risk for cardiovascular
Fortified
Cereals disease, elevated blood pressure, blood
Vitamin K Broccoli Ecchymotic lipids, and blood glucose levels.
Cabbage lesions  It increases risk for colorectal cancer,
Turnip breast, and prostate cancer.
greens  The outcome management of obesity
Green tea includes: diet, behavior modification,
Manganese Whole Magenta
exercise, and occasionally medication. If
grains tongue
Legumes Dermatitis these therapies fail, surgical treatment
Nuts may be considered (e.g., jeju-ileal
Tea bypass, gastric stapling).
Niacin Organ Sore,  Metabolic Syndrome
Meats reddened  Increased BP
Brewer’s tongue and  Insulin resistance
yeast mouth
 Excess body fats/ obesity
Peanuts Angular
Fish stomatitis around waist (apple
Poultry Seborrhea – shape)/Central obesity
Whole like dermatitis  Elevated triglycerides
grains  Low HDL levels
Beans  High blood pressure
Riboflavin Liver Angular 2. Anorexia Nervosa and Bulimia Nervosa
Milk stomatitis
 Anorexia Nervosa intentionally
Cheddar Seborrhea –
cheese like dermatitis imposes severe dietary restrictions,
Cottage Alopecia resulting in weight loss, endocrine
cheese dysfunction, and fluid and electrolyte
Yogurt imbalance. Body image is distorted
Brewer’s and attitude toward eating is
yeast impaired
Zinc Oysters
 Bulimia Nervosa is characterized by
Wheat germ
Beef frequent binge eating and purging
Cheese (vomiting). Abuses laxatives and
 Pellagra diuretics.
 Vitamin B3 (Niacin) deficiency  Physical Manifestations of Anorexia
 Clinical Manifestations: Nervosa
 Scaly rashes (dermatitis)  Dizziness, Confusion
 Mucosal inflammation  Dry, brittle hair
 Mental changes (e.g. dementia)  Lanugo – type hair
 Sensitivity to sunlight  Low BP, pulse, ECG voltage
 Diarrhea  Orthostasis
 Alopecia  Cachexia
 Edema  Biochemical changes:
 Insomnia WBC- Up, Glucose Down,
 4 D’s of Pellagra Cholesterol- Up, Carotene-
 Dermatitis Up
 Diarrhea  Stool retention
 Dilated cardiomyopathy  Acrocyanosis
 Dementia  Amenorrhea
 Treatment: Niacin/Niacinamide  Muscle wasting
 Eating Disorders  Diminishing DTRs
 Osteoporosis
  Dry skin  Management: (Prevention and
 Edema treatment):
 Growth retardation o Regular brushing/flossing
 Hypothermia o Diet: low simple
 Physical Manifestations of Bulimia carbohydrate
Nervosa o Fluoridation
 Salivary gland enlargement o Regular visit to the dentist
 Enamel erosion (usually biannual or as
 Esophagitis prescribed)
 Arrythmias o Cleaning, treatment of
 Normal weight or underweight caries
 Callus in the fingers o Filling
 Biochemical changes: (K-Down,
o Extraction
CD2- Down, Amylase- Up)
o Root canal treatment
 Diarrhea
(pulpectomy)
 Edema
3. Periodontal Diseases
 Russel sign (Bruised knuckles
 Gingivitis – inflammation of the
due to self-induced vomiting)
gums with gum bleeding, reddening,
 Nursing Diagnosis for the Client with
swelling, ulceration
Eating Disorders
 Periodontitis / pyorrhea –
o Altered nutrition: Less than body
inflammation extends from the gums
requirements related to
into the alveolar bone and
inadequate food intake
periodontal attachment  destroy
(anorexia nervosa)
supporting structures of the teeth 
o Altered Nutrition: More than
teeth loosen and fall out.
body requirement related to
 Management:
increased food intake (bulimia
o Good oral hygiene
nervosa and obesity)
o Lessen frequency of meals
o Body image disturbance related
o Minimize snacks
to misconception of body size or
o Relieve pain
negative feelings (all disorders)
o Risk for injury: Dysrhythmias 4. Malocclusion – mal-alignment of teeth.
Requires orthodontic treatment
related to hypokalemia (both
5. Impacted third molar – Requires surgical
anorexia and bulimia)
removal of the third molar.
II. Management of Patients with Ingestive
Disorders
 Dental Disorders
1. Dental Plaque
 Soft mass of proliferating bacteria
with scattering of leukocytes,
macrophages and epithelial disease
in a sticky polysaccharide protein
matrix that adhere to the teeth.
 Transparent, colorless in
appearance
 Carbohydrates contribute to plaque
formation
2. Dental Caries / Tooth Decay
 Erosive process that can cause
progressive demineralization and
destruction of the outer enamel of
the tooth.
 Acid production, bacteria and
carbohydrate result to dental caries