Gastrointestinal Tract System Notes

SCREENING and ASSESSMENT of THE NUTRITIONAL STATUS ▄ Nutritional Health – result of consistently meeting the body’s nutrient requirements - determine average nutritional requirements by published standards such as RDA or food guide pyramid - adequacy of a client’s diet = use a food diary and compare the nutritional intake with RDA - RDA - Food Guide Pyramid ▄ Malnutrition – a condition resulting from excessive or inadequate nutrient availability over an extended period. *starvation – inadequate delivery of nutrients to the body. Types: 1. Primary malnutrition – adequate nutrition is not delivered to the upper GIT over an extended period 2. Secondary malnutrition – occurs when GIT fails to absorb, metabolize or use nutrients 3. Mixed type malnutrition – inadequate calorie/protein intake with increased nutritional requirements Protein and Calorie Deficiency Malnutrition 1. Kwashiorkor – inadequate protein intake but with adequate calorie intake - moon-like flabby face, edema, body weight at above ideal range, visceral CHONs below normal 2. Marasmus – inadequate calorie and protein intake - BW and anthropometric appearance below normal, old man facie, cachectic appearance, visceral CHONs within normal * Micronutrient malnutrition – occurs when vitamins, minerals, trace elements are not absorbed, delivered or used by GIT - vitamins, minerals, trace elements deficits occur in combination. It is difficult to identify deficit of single micronutrient *Obesity – may result from nutrient delivery that exceeds the client’s nutritional requirement I. History taking ▄ Biographical and Demographic Data - analyze client’s demographic data within the context of nutritional status and upper GI function- women are at risk for problems r/t calcium deficiency - culture, religion and ethnic origin may also affect the type, amount and frequency of dietary consumption ▄ Chief complaints (n/v, indigestion, abdo pain, diarrhea, changes in weight or appetite) -clinical manifestations that are related to nutritional status and upper GI function -do symptom analysis ▄ Symptom analysis a. nausea and vomiting – onset, duration, aggravating factors - characteristic of vomitus = amount, color = does the vomitus contains bile or undigested food? - pain with n/v b. indigestion – RT food intake, which food worsen or relieve the manifestations? -medications- (antacids) - description- burning or burping c. abdominal pain – PQRST -associated manifestations- fever – increased or relieved with movement? Does food exacerbate pain? Sources and Characteristics of Abdominal Pain a. Intestinal obstruction – distended abdomen, no bowel movements or flatus - intermittent or colicky pain - RUQ pain radiating to shoulder (associated with gall bladder) - pain near umbilicus (associated with small bowel) - lumbar pain ((associated with colon) b. Peritoneal inflammation – (perforated ulcer, ruptured spleen, ruptured appendix) - steady aching pain over area of inflammation - pain increasing with motion - intensity of pain varying with source of inflammation (gastric acid may produce more pain than alkaline content of small bowel) - sometimes associated with manifestation of shock c. Vascular obstruction – may be preceeded by 2-3 days of mild-moderate pain and hyperperistalsis, folwed by severe abdominal pain and manifestations of shock. d. weight and appetite changes – determine usual appetite and weight - amt of weight loss or weight gain- diet- -causes

e. diarrhea –color amount - how many stools expelled per day?how much? Consistency- liquid or solid? Color- back, tarry or bloody? -associated manifestations = pain, abdominal cramping or bloating, time, fecal incontinence *steatorrhea – fatty, foul-smelling stool - non specific GI problems such as N/V and diarrhea can result from food-borne poisoningduration- provoking factors - relationship of stool and dietary intake - assess fluid and electrolyte balance *vomiting – metabolic alkalosis (hcl) *diarrhea – metabolic acidosis (HCO3) * Lactose intolerance ▄ Past Health History a. Major Illnesses and Hospitalization - can provide clues about nutritional status and function of upper GIT hospitalization due to GI s/sx-PUD, hematemesis, anemia, jaundice, gallbladder disease - diagnostic tests of upper GI = clues about current health problem and serve as baseline data - past surgical procedures -> ask about surgery of the mouth, throat, stomach, liver, pancreas, gallbladder, abdomen b. Medications – OTC, prescribed, herbal medications - aspirin, aspirin compounds, NSAIDs = gastritis - antacids, laxatives, stool softeners – frequency of use? - vitamins and minerals = iron – may cause gastric irritation and can change stool color and consistency c. Nutritional supplements – vitamins, minerals, herbs, amino acids, meal supplements or replacements - can be harmful if taken in excess or in combination with other drugs - in excessive doses, vitamins can cause toxic side effects d. Allergies – hives, dyspnea, GI manifestations (cramping, flatulence, diarrhea) after food intake *Lactose intolerance- common condition for many adults because of inadequate amount of lactase (enzyme in the bowel) ->cannot break down lactose molecules->abdo cramping and drh

e. Family Health History- history of cancer, ulcer, UC, crohn’s disease ▄ Psychosocial History

a. occupation – toxic substances in the workplace (arsenic, lead, Hg) -

b. -

recent travels to foreign countries – increases risk of contracting GI dse.,caused by pathogenic bacteria, protozoa, helminthes & other parasites nutrition – type and amount of food intake are influenced by psychosocial factors describe a typical meal alcohol intake appetite food intake record= two weekdays and one weekend day = to determine dietary intake average healthy person: 30 to 35 cal/kg and 0.8 to 1.2 g of protein/ kg

▄ ROS - condition of the mouth- dental caries, number and condition of teeth - oral lesions, halitosis, increased or decreased salivation - brushing of teeth, visit to the dentist - trouble chewing or swallowing - dysphagia, odynophagia - change in bowel habits or stool characteristics - changes in appetite - problems of hepatic or biliary systems (jaundice, pruritus, ascites, dark-colored urine, acholic stools, bleeding problems II. Physical Examination ▄ Anthropometric measures – provide an assessment of body mass or body compartments 1. Height or weight - Weight = balance scale, calibrated sling, wheel chair scale - Height = telescoping ruler; arm span measurement - determine weight changes (current weight/ usual weight x 100) - weight changes of less than 90% or more than 110% of the client’s usual weight is significant

2. Body Mass Index- acceptable method of standardizing height for weight measurement

BMI= weight in kg/ height in meters2 = weight in lbs/ height in inches2 x 703 18.5 or less

Underweight

18.5 – 24.9

Normal

25.0 – 29.9

Overweight

30.0 – 39.9

Obese

40 or greater

Extremely Obese

▄ Mouth Inspection - lips = symmetry, color, hydration, lesions, nodules - teeth = number and position; dental caries, missing or broken teeth, = erythroplakia (red lesions); leukoplakia (white lesions) - pharynx = tonsillitis - tongue = symmetry, color, moisture = Palpation - lips, gingivae, buccal mucosa = loose teeth, masses, swelling, areas of tenderness - tongue = lesions, masses, color changes - dysphagia – - tonsils – ▄ AbdomenInspection - skin, abdominal contour = smooth, intact, with varying amounts of hair, flat, concave or rounded= areas of distention or irregular contour = rashes, discoloration, scars, petechiae, striae - umbilicus = concave, located at the midline, no drainage and same color of the abdo skin - peristaltic movement or abdominal pulsation Auscultation- RLQ, RUQ, LUQ, LLQ- clockwise fashion - Normal bowel sounds: every 5 to 15 sec; occur irregularly at a rate of 5 to 35 per minute - borborygmi = loud, high-pitch bowel sounds = hyperactive GIT - hypoactive bowel sounds = bowel sound of 1 or fewer every minute - use the bell of the steth to auscultate for vascular sounds = bruit, venous hum, friction rub • bruit- vascular turbulence - aneurysm or partial obstruction of the vessel • venous hum- heard in the periumbilical area indicates engorged liver circulation • friction rub- two pieces rubbing together; suggest hepatic tumor when heard loudest over the lower right rib cage or splenic inflammation when hear loudest over the lower rib cage in the anterior axillary line Percussion - size and location of abdominal organs and to determine fluid, air or masses - high-pitch, loud, musical sounds over gas-filled organs- tympanic - dull sounds over fluid or solid organs- thud like - determine size and position of liver and spleen Palpation- systematic quadrant to quadrant or region to region - begin with non-tender areas and progressing to painful ones - light palpation = 1 to 2 cm depression - deep palpation = size and shape of abdominal organs and masses - * rebound tenderness DIAGNOSTIC PROCEDURES A. ACID PERFUSION TEST AKA: Bernstein Test Description: In this test, normal saline and acidic solutions are perfused separately into the esophagus through a nasogastric tube. Purpose: To distinguish heartburn-like pains caused by esophagitis from those caused by cardiac d/o. Nursing Responsibilities Pre-Test • Explain the procedure and purpose of the test •

Instruct the patient to observe the following pretest restrictions:  No antacids for 24 hrs. as ordered  No food for 12 hrs.

 No fluids and smoking for 8 hrs. •

Inform pt. that some discomfort, coughing or gagging may be experienced during tube passage

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Inform pt. to report pain or burning sensation during perfusion

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Immediately before the test, check pt.’s PR & BP

During the Test • Insert NGT that has been marked 12” from the tip into pt.’s stomach, aspirate stomach content, then withdraw the tube into the esophagus. •

Hang labeled containers of NSS and 0.1 N HCL Solution on an IV pole then connect NGT to IV tubing.

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Open the line from NSS @ 60-120gtts/min for 5-10 mins. then note pt.’s response.

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Close the line from NSS then open the line from HCL solution, same rate with NSS but to run for 30 mins., then note pt.’s response

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Stop the solution and withdraw NGT if the pt. experiences no discomfort after perfusion of HCL for 30 mins.

Post-Test • Administer antacid as ordered •

Provide soothing lozenges or ice collar as ordered

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Patient may resume normal diet and medications as ordered

Nursing Alert!!! • Observe the pt. closely for arrhythmias •

Withdraw the tube immediately if the pt. develops cyanosis or paroxysmal coughing

Normal Finding: • Absence of pain Abnormal Finding: • Acidic solution causes pain or burning sensation (esophagitis) B. BARIUM SWALLOW AKA: Upper GI Series Description: Is a fluoroscopic and x-ray examination of the esophagus, stomach and small intestine Purpose: • To detect ulcer, polyps, tumor, hernia, varices, strictures and foreign bodies Nursing Responsibilities Pre-Test • Explain the procedure and purpose to the client •

Record V/S

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The client should be NPO and refrain from smoking for 8-12 hrs

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Withhold medications for 8 hrs unless indicated

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Inform the pt. That the test does not cause significant discomfort

Post-Test • Check with the radiology department that the Upper GI Series and/or small bowel series are completed before giving meal •

Administered the ordered laxatives

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Instruct client to increase fluid intake

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Inform the client that the stools should be light in color for the next several days

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Instruct the client to notify HCP if he/she does not have bowel movement in 2-3 days

Normal Findings:  The bolus evenly fills and distends the lumen and the mucosa appears smooth and regular, normal peristalsis Abnormal Findings:  ulcer, polyps, tumor, hernia, varices, strictures and foreign bodies

C. BARIUM ENEMA AKA: Lower GI Series Description: Radiographic examination of the large intestine after rectal instillation of barium sulfate 2 Types a. Single Contrast (only barium sulphate)- provides a profile view of the large intestine b. Double Contrast (Barium sulphate and air)- provides profile nad frontal view. It is better for detecting small intraluminal tumors (esp. Polyps) Purpose: • To aid diagnosis of colorectal cancer and inflammatory diseases •

To detect polyps, diverticula, and structural changes in the colon

NURSING RESPONSIBILITIES Pre-Test • Explain the procedure and purpose of the test •

Oral medications should not be given for 24 hrs unless indicated

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Instruct the pt. to restrict dairy products and to follow a liquid diet for 24 hrs

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Instruct pt. to drink 8-oz of water or clear liquid for 12 to 24 hrs

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Inform patient that he/she will assume several position during instillation of barium.

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Prescribe laxatives to be taken the day before the test

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Administer a bowel preparation

Post-Test • The client should expel the barium in the bathroom or bedpan immediately after the test •

Instruct pt. to increase fluid intake

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Encourage rest

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Administer laxative such as milk of magnesia or magnesium citrate or give cleansing enema as ordered

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Inform pt. That the stool will be light colored for 24-72 hrs

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Absence of stool should be reported

Nursing Alert!!! • Barium enema is contraindicated in pt. With tachycardia, severe ulcerative colitis, active GI bleeding, suspected perforation •

The test is contraindicated to pregnant patient

Normal Findings: Single Contrast: The intestine is uniformly filled with barium and mucosa has a regular and feathery appearance Double Contrast: The intestine is uniformly distended with air, with a thin layer of barium providing excellent detail of the mucosal pattern Abnormal Findings: • Carcinoma, IBD, diverticula, fistulas, polyps, intussusception D. FECAL OCCULT BLOOD TEST Description: A microscopic analysis or chemical test for hemoglobin that determines hidden or invisible blood (occult) in the stool. Purpose: • To detect GI bleeding •

To aid early diagnosis of colorectal cancer

NURSING RESPONSIBILITIES • Explain the procedure and purpose to the client •

Obtain hx of recent or past bleeding episodes

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Instruct the client to maintain high-fiber diet and to refrain from eating red meat, poultry, fish, green leafy vegetables for 48-72 hrs

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Instruct the client to withhold ascorbic acid, iron preparations, salicylates, and steroids for 48 hrs

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Instruct client to report epigastric pain and abnormal-colored stool

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Be sure the stool is not contaminated with menstrual discharge

Normal Finding: • Negative (Green Rxn)- less than 2.5 ml of blood in the stool Abnormal Finding: • Positive (Blue Rxn)- more than 2.5 ml of blood in the stool E. PERCUTANEOUS LIVER BIOPSY Description: • Insertion of needle through the skin which involves needle aspiration of a core tissue for histologic analysis Purpose: • To diagnose hepatic parenchymal disease, malignant tumors and granulomatous infections NURSING RESPONSIBILITIES Pre-Test • Explain the procedure and purpose of the test •

Instruct the pt. to restrict food and fluids for 4-8 hrs

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Secure an informed consent

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Check pt. hx for hypersensitivity to local anesthesia

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Make sure PT, PTT, and platelet count are performed and recorded

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Instruct pt. to void before biopsy

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Record V/S

During the Test • Instruct pt. to assume supine position with his right hand under his head •

Drape and clean the area of injection

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Instruct pt. to hold his breath while needle biopsy is inserted in the liver

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Apply pressure to the biopsy site to stop bleeding

Post-Test • Position pt. On his right side for 2 hours, with small pillow or sandbag under the costal margin

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Check pt. V/S q 15 mins. For the 1 hr., then q 30 mins. for 4 hrs, and q 4 hrs for 24 hrs

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Observe carefully for signs of bleeding and shock

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Administer analgesic as ordered

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Provide rest and pt. may resume normal diet

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Send the specimen to the laboratory immediately

Nursing Alert!!! • Watch for bleeding, signs of shock, bile peritonitis and pneumothorax -S/SX of bile peritonitis: tenderness and rigidity around the biopsy site -S/SX of pneumothorax: risisng RR, depressed breath sounds, dyspnea, persistent shoulder pain, and pleuritic chest pain Normal Findings: • Normal liver cells Abnormal Findings: • Presence of malignancies and hepatic diseases F. CT Scan AKA: CAT Scan, CTT Scan, CATT Scan - Computed Axial Tomography (CAT), Computed Transaxial Tomography (CTT), Computed-assisted Transaxial Tomography Description: It produces a narrow x-ray beam that examines body sections from many different angles.

Purpose: To produce tissue analysis and images not readily seen on standard radiographs Pre-Test: • Explain the procedure and purpose of the test •

A consent form should be signed

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NPO for 4 hrs if contrast dye is used

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Assess pt. allergy to iodine products

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Remove all metal objects and jewelry

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Instruct pt. to wear loose and comfortable clothing

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Administer sedative as ordered

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Enema may be ordered

During the Test • Instruct client to remain still during the procedure •

Instruct pt. That holding breath may be requested

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Instruct pt. To report unusual sensation especially if contrast dye is used

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Observe for S/Sx of severe allergic rxn to the contrast dye

Post-Test: • Observe for delayed allergic reaction to the contrast dye •

Instruct pt. To increase fluid intake to enhace the excretion of contrast dye

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Instruct the client to resume his/her usual activity and diet as indicated

Nursing Alert!!! • Watch for dyspnea, palpitations, tachycardia, itching and urtucaria G. ULTRASONOGRAPHY AKA: Ultrasound, Sonogram Description: A procedure used to visualize body tissue structure or wave-form analysis of Doppler studies Purpose: • To detect tissue abnormalities NURSING RESPONSIBILITIES Pre-Test: • Explain the procedure and the purpose of the test •

Obtain a signed consent form

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Restrict food and fluids for 4-8 hrs

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Advise pt. To eat fat-free meal night prior to the test

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Instruct client not to smoke or chew gum prior to the test

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Inform pt. that this is a painless procedure

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Enema may be performed as ordered

During the Test: • Ask the client to breathe slowly and to hold breath after deep inspiration •

Instruct client to remain still during the test

Post-Test: • Instruct the client to resume his/her usual activity and diet as indicated H. X-RAY AKA: Radiography, Roentgenography Description: A procedure that emits x-radiation that is used to identify structure, size, and shape of bone and body tissues Purpose: • For Screening purposes

NURSING RESPONSIBILITIES • Explain the procedure and the purpose of the test •

Ask female client if she is pregnant

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Foods and fluids are not usually restricted

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X-ray should be taken before GI series

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Clothes are removed and cloth gown is worn

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Instruct pt. to lie in supine position with his arms away from the body