ANATOMY AND PHYSIOLOGY

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2 ANATOMY AND PHYSIOLOGY Functions of the gastrointestinal (GI) system: * Process food substances * Absorb the products of digestion into the blood * Excrete unabsorbed materials * Provide an environment for microorganisms to synthesize nutrients, such as vitamin K

3 Mouth Contains the lips, cheeks, palate, tongue, teeth, salivary glands, muscles and maxillary bones Saliva contains the amylase enzyme (ptyalin) that aids in digestion Mechanical and chemical digestion originate here

4 Esophagus A muscular tube, about ten inches long Carries food from the pharynx to the stomach Upper esophageal sphincter (UES) Lower esophageal sphincter (LES)

5 Stomach A hollow muscular pouch Secretes pepsin, renin, lipase, mucus and hydrochloric acid for digestion Mixes and stores chyme Secretes intrinsic factor necessary for absorption of vitamin B12

6 Small Intestine (3) Main Functions: Movement (mixing & peristalsis) Digestion of food Absorption of nutrients

7 Small Intestine Duodenum: Contains the openings of the bile and pancreatic ducts and is approximately 12 inches long Jejunum: Approximately 8 feet long Ileum: Approximately 12 feet long Terminates into the cecum

8 Small Intestine Chyme, in liquid or semiliquid form, enters the duodenum through the pyloric sphincter Bile and pancreatic secretions enter the duodenum through the common bile duct

9 (3) Main Functions: Movement Absorption Elimination Large Intestine

10 Large Intestine Consists of the cecum, colon, rectum and anus Absorbs fluids, synthesizes Vitamin K using intestinal bacteria and stores fecal material Chyme becomes more solid as the intestinal wall of the colon absorbs water and wastes Defecation is the movement of feces from the rectum through the anal sphincter Approximately 5 to 6 feet in length

11 Ascending Transverse Descending Sigmoid Rectum Large Intestine (Colon)

12 Assessment Findings History Culture Inadequate diet Change in bowel habits Constipation Diarrhea Flatus

13 Assessment Findings Cont. Indigestion/heartburn Abdominal pain Dysphagia Loss of appetite Unintentional weight loss or gain

14 Objective Data Associated With GI Disorders Weight changes Abnormal color and consistency of stool Melena Clay-colored stool Frothy stools Occult blood in stool Abnormal bowel sounds

15 Objective Data Associated With GI Disorders Abdominal distention Rectal bleeding Jaundice Edema Hematemesis Anorexia Changes in skin

16 Diagnostic Tests And Procedures Upper GI tract study (barium swallow): Teaching preprocedure? Teaching postprocedure?

17 Diagnostic Tests And Procedures Lower GI tract study (barium enema) Teaching preprocedure? Teaching postprocedure?

18 Diagnostic Procedures Upper GI fiberoscopy: Esophagogastroduodenoscopy (EGD) Following sedation, an endoscope is passed down the esophagus to view the gastric wall, sphincters and duodenum; tissue specimens can be obtained

19 Diagnostic Procedures Pre-procedure: NPO for 6 to 8 hours prior to the test A local anesthetic (spray or gargle) is administered along with midazolam (Versed) which provides conscious sedation and relieves anxiety just before the scope is inserted Atropine may be administered to reduce secretions and glucagon may be administered to relax smooth muscle

20 Diagnostic Procedures Client is positioned on the left side to facilitate saliva drainage and to provide easy access of the endoscope Airway patency is monitored during the test and pulse oximetry is used to monitor oxygen saturation; emergency equipment should be readily available

21 Diagnostic Procedures Post-procedure: NPO until the gag reflex returns (1 to 2 hours) Monitor for signs of perforation (pain, bleeding, unusual difficulty in swallowing, elevated temperature) Maintain bed rest for the sedated client until alert Lozenges, saline gargles, or oral analgesics can relieve minor sore throats after the gag reflex returns

22 Diagnostic Procedures Proctoscopy and Sigmoidoscopy: Use of a flexible scope to examine the rectum and sigmoid colon; client is placed on the left side with the right leg bent and placed anteriorly Biopsies and polypectomies can be performed Pre-procedure: Enemas until the returns are clear Post-procedure: Monitor for rectal bleeding and signs of perforation

23 Diagnostic Procedures Fiberoptic Colonoscopy: A fiberoptic endoscopy study in which the lining of the large intestine is visually examined; biopsies and polpectomies can be performed Cardiac and respiratory function is monitored continuously during the test Performed with the client lying on the left side with the knees drawn up to the chest; position may be changed during the test to facilitate passing of the scope

24 Diagnostic Procedures Pre-procedure: Adequate cleansing of the colon is necessary as prescribed by the physician A clear liquid diet is started hours before procedure NPO 6-8 hours before procedure Midazolam (Versed) IV is administered to provide sedation

25 Diagnostic Procedures Post-procedure: Provide bed rest until alert Monitor vital signs Monitor for signs of perforation Instruct the client to report any bleeding to the physician Instruct client may experience abdominal fullness and cramping even a few hours after

26 Laparoscopy: Diagnostic Procedures Performed with a fiberoscopic laparoscope that allows direct visualization of organs and structures within the abdomen; biopsies may be obtained

27 Paracentesis: Diagnostic Procedures Transabdominal removal of fluid from the peritoneal cavity for analysis

28 Diagnostic Procedures Pre-procedure: Obtain informed consent Void prior to the start of procedure to empty bladder and to move bladder out of the way of the paracentesis needle Measure abdominal girth, weight and baseline vital signs Client is positioned upright on the edge of the bed with the back supported and the feet resting on a stool

29 Diagnostic Procedures Post-procedure: Monitor vital signs Measure fluid collected, describe and record Label fluid samples and send to the lab for analysis Apply a dry sterile dressing to the insertion site; monitor site for bleeding

30 Diagnostic Procedures Measure abdominal girth and weight Monitor for hypovolemia, electrolyte loss, mental status changes or encephalopathy Monitor for hematuria resulting from bladder trauma Instruct the client to notify the physician if the urine becomes bloody, pink or red

31 Fecal Occult Blood Test Lab test using a reagent Analysis for blood in stool

32 Blood Tests CBC PT Electrolytes AST, ALT, Amylase, Lipase, Bilirubin

33 Abdominal Assessment Inspect for skin color, symmetry and abdominal distention Auscultate for bowel sounds Percuss for air or solids Palpate for tenderness

34 Bowel Sounds Auscultate bowel sounds before percussion and palpation Normal bowel sounds occur 5 to 30 times a minute or every 5 to 15 seconds Auscultate in all abdominal quadrants Listen at least one full minute in each quadrant before assuming sounds are absent

35 GI Pharmacologic Management Proton Pump Inhibitors Antacids Histamine H2 Receptor Antagonists Anticholinergics Mucosal Barrier Fortifiers/Cytoprotectants Prostaglandin Analogues Antiemetics Laxatives/Bowel Cleansers *Antimicrobials Antidiarrheals *Prokinetics

36 Gastroesophageal Reflux Disease Definition: (GERD) Backflow (reflux) of gastric or duodenal contents into the esophagus and past the lower esophageal sphincter(les)

37 Impaired LES GERD (Etiology) Increased intra-abdominal pressure (obesity, pregnancy, constricting waistline, bending over and ascites) Alcohol ingestion Smoking

38 GERD (Etiology) Cont. Gastric distention from large meals Delayed gastric emptying Certain foods Nasogastric tube placement Meds- calcium channel blockers, anticholinergics and nitrates

39 GERD Pathophysiology Reflux occurs when LES pressure is deficient or when pressure within the stomach exceeds LES pressure (heartburn) Acidic contents cause injury and inflammation to esophageal mucosa

40 GERD (Assessment Findings) Dyspepsia (pyrosis or heartburn) in epigastric region, may radiate to jaw or arms, occurs after meals Pain worsens with lying down or bending over Hypersalivation Regurgitation Dysphagia and Odynophagia Belching Nausea

41 GERD Diagnostic Tests Esophageal acidity 24 hour test- reveals reflux Endoscopy- allows visualization and confirmation of pathologic changes in the mucosa Esophageal manometry- evaluates LES pressure

42 Medical Management: GERD Diet- small frequent meals, avoid meals before bedtime Diet therapy Position upright during and after meals, sleep with HOB elevated Smoking/Alcohol Cessation

43 GERD (Drug Therapy) Inhibit gastric acid secretion Accelerate gastric emptying Protect the gastric mucosa Examples: Antacids- Maalox H2-antagonists- Tagamet, Zantac Proton pump inhibitors- Prilosec, Prevacid Prokinetics- Reglan

44 GERD WHAT IS A SERIOUS COMPLICATION OF GERD?

45 GERD NURSING INTERVENTIONS??? (Health Promotion to avoid surgery)

46 GERD Procedures Endoscopic therapies: Stretta procedure BESS procedure Surgical Procedure: Laparoscopic Nissen Fundoplication (LNF)

47 Hiatal Hernia Also known as esophageal or diaphragmatic hernia A portion of the stomach protrudes or herniates through the diaphragm and into the thorax It results from weakening of the muscles of the diaphragm and is aggravated by factors that increase abdominal pressure, such as pregnancy, ascites, obesity, tumors and heavy lifting Sliding vs. Rolling

48 Hiatal Hernia Complications include ulceration, hemorrhage, regurgitation and aspiration of stomach contents, strangulation, and incarceration of the stomach in the chest with possible necrosis or peritonitis

49 Assessment Findings: Heartburn Regurgitation or vomiting Dysphagia Feeling of fullness Pain Belching Hiatal Hernia

50 Implementation: Hiatal Hernia Medical and surgical management is similar to that for GERD Provide small, frequent meals and minimize the amount of liquids Advise the client not to recline for several hours after eating Nissen procedure, if needed

51 Esophageal Cancer Usually squamous cell or adenocarcinoma Commonly found in the upper third of the esophagus Early spread to the lymph nodes is common

52 Esophageal Cancer (Silent Tumor) Contributing factors include: Heavy use of tobacco and alcohol Chronically low intake of fresh fruits and vegetables Chronic irritation- GERD or chronic gastritis Obesity Malnutrition

53 Esophageal Cancer Assessment Findings: Dysphagia Odynophagia Feeling of food sticking in throat Nocturnal aspiration Regurgitation

54 Esophageal Cancer Assessment Findings Cont.: Eventually inability to swallow liquids Changes in bowel habits Chronic cough with increasing secretions Nausea/Vomiting Anorexia Weight loss

55 Esophageal Cancer- Diagnostics Barium Swallow- (done first) EUS- (definitive) EGD PET Scan CT Scan

56 Esophageal Cancer Treatment: Nutrition therapy Swallowing therapy Antineoplastic agents, radiation or combo Photodynamic therapy Esophageal dilation Surgery to resect tumor Gastrotomy to maintain nutrition

57 Esophageal Cancer Nonsurgical Management???

58 Esophageal Cancer Surgical Management: Esophagectomy- the removal of all or part of the esophagus Esophagogastrostomy- the removal of part of the esophagus and proximal stomach

59 Esophageal Cancer Preoperative Care: (Teaching) Stop smoking Nutritional support (supplementation) Monitor weight Monitor I & O Meticulous oral care TCDB

60 Esophageal Cancer Preoperative Care: (Teaching) Cont. Post-op respiratory care The number and sites of all incisions and drains The placement of a jejunostomy tube May need chest tubes The need for IV infusion The purpose of the NG tube

61 WHAT ARE NASOGASTRIC TUBES USED FOR?

62 Esophageal Cancer THE PATIENT WILL HAVE AN NG TUBE DURING THIS SURGERY, WHY?

63 Esophageal Cancer NURSING INTERVENTIONS FOR NG TUBE AFTER SURGERY???

64 Esophageal Cancer NURSING INTERVENTIONS AFTER SURGERY???

65 Esophageal Cancer DISCHARGE INSTRUCTIONS AFTER SURGERY???

66 Gastritis Inflammation of the stomach or gastric mucosa Acute: caused by the ingestion of food contaminated with disease-causing microorganisms or food that is irritating or too highly seasoned, the overuse of aspirin or other nonsteroidal anti-inflammatory drugs (NSAIDS), excessive alcohol intake, local irritation from radiation therapy, caffeine, the bacteria Helicobacter Pylori

67 Gastritis Chronic: caused by benign or malignant ulcers, or by the bacteria Helicobacter pylori; may also be caused by autoimmune diseases, dietary factors, medications, alcohol, smoking, or radiation The result is hypermotility of the GI tract, leading to altered secretions of fluids and electrolytes Increased risk for gastric cancer

68 Gastritis (Acute) Assessment Findings: Rapid onset of epigastric pain or discomfort Nausea and vomiting Hematemesis Gastric hemorrhage Dyspepsia Anorexia

69 Assessment Findings: Gastritis (Chronic) Vague complaint of epigastric pain that is relieved by food Anorexia, Nausea or Vomiting Intolerance of fatty and spicy foods Vitamin B12 deficiency/pernicious anemia

70 Diagnostic Test: EGD with biopsy Gastritis Surgical Intervention- None * Unless bleeding or ulceration (partial gastrectomy, pyloroplasty, vagotomy or total gastrectomy)

71 Descriptions: Gastric Surgery Vagotomy- surgical ligation of the vagus nerve to decrease the secretion of gastric acid Pyloroplasty- enlarges the pylorus to prevent or decrease pyloric obstruction, thereby enhancing gastric emptying Gastroduodenostomy- (Billroth I)- surgical removal of the lower portion of the stomach with anastomosis of the remaining portion of the stomach to the duodenum

72 Gastric Surgery Gastrojejunostomy- (Billroth II)- partial gastrectomy with remaining segment anastomosed to the jejunum Esophagojejunostomy- (Total Gastrectomy)- surgical removal of the entire stomach with a loop of the jejunum anastomosed to the esophagus

73 Gastritis NURSING INTERVENTIONS???

74 Peptic Ulcer Disease (PUD) An ulceration in the mucosal wall of the stomach, pylorus, duodenum, or esophagus, in portions that are accessible to gastric secretions; erosion may extend through the muscle May be referred to as gastric, duodenal, or stress ulcers, depending on location The most common peptic ulcers are gastric ulcers and duodenal ulcers

75 Pathophysiology: Peptic Ulcer Increased emptying time of gastric acid from the gastric lumen into the small intestine causes an inflammatory reaction with tissue breakdown Combination of hydrochloric acid and pepsin destroys gastric mucosa

76 Peptic Ulcer Causes: Drug induced: NSAIDS, ASA, Corticosteroids, etc. Infection- Helicobacter pylori Smoking Alcohol abuse Gastritis Caffeine Stress

77 Assessment Findings: Gastric Ulcers Gnawing, sharp pain in or left of the midepigastric region minutes after eating Hematemesis Pain that is increased from eating

78 Assessment Findings: Duodenal Ulcers Burning pain one and a half to three hours after eating and during the night Pain that is often relieved by eating Melena

79 Gastric Ulcers Diagnostic Test Findings: Decreased HGB & HCT Fecal occult blood- positive EGD

80 Complications: Hemorrhage Perforation Pyloric Obstruction Intractable Disease Peptic Ulcers

81 Surgical Implementation: Peptic Ulcers Surgery is performed only if the ulcer is unresponsive to medications or if hemorrhage, obstruction, or perforation occurs

82 Peptic Ulcers NURSING INTERVENTIONS???

83 Gastrointestinal Bleeding Assessment Findings: Coffee-ground vomitus Tarry stools or frank blood in stools Melena Decreased B/P

84 Gastrointestinal Bleeding Assessment Findings Cont.: Increased weak and thready pulse Decreased HGB and HCT Vertigo Acute confusion (in older adults) Dizziness Syncope

85 Gastrointestinal Bleeding Common causes of upper GI bleeding: Esophageal cancer Esophageal varices Gastritis Gastric ulcer Gastric cancer Duodenal ulcer

86 Gastrointestinal Bleeding Common causes of lower GI bleeding: Ulcerative colitis Polyps Colon cancer Diverticulosis/Diverticulitis Rectal cancer Hemorrhoids Peptic ulcer disease Crohn s disease

87 Gastrointestinal Bleeding Interventions: Hypovolemia management Bleeding reduction/non-surgical management: Nasogastric tube placement Saline/water lavage

88 Gastrointestinal Bleeding Interventions Cont.: Endoscopic therapy (EGD) Acid suppression Surgical Management: Minimally Invasive Surgery via Laparoscopy vs. Conventional Surgery

89 Definition: Gastric Cancer Malignant neoplasms in the stomach

90 Pathophysiology: Gastric Cancer Unregulated cell growth and uncontrolled cell division result in the development of a neoplasm Tumor usually develops in the distal third of stomach and metastasizes to the abdominal organs, lungs and bones Most common neoplasm is adenocarcinoma

91 Gastric Cancer Causes: Infection with H. pylori High intake of salty and smoked foods Chronic gastritis Pernicious anemia Gastric ulcer Smoking and alcohol consumption

92 Gastric Cancer Assessment Findings: (Early) Indigestion Feeling of fullness Epigastric, back, or retrosternal pain Abdominal discomfort initially relieved with antacids

93 Gastric Cancer Assessment Findings: (Advanced) Nausea and vomiting Progressive weight loss Palpable epigastric mass Enlarged lymph nodes Weakness and fatigue Obstructive symptoms Iron deficiency anemia

94 Diagnostic Lab Test Findings Fecal occult blood positive CEA positive Decrease in HGB and HCT

95 Diagnostic Tests EGD EUS CT scan PET MRI

96 Gastric Cancer Nonsurgical Management: Depends on stage of disease Chemotherapy Radiation Side effects

97 Complications: Obstruction Ulceration Metastasis Gastric Cancer

98 Gastric Cancer Surgical Management: Total gastrectomy Partial gastrectomy MIS (minimally invasive surgery) Palliative resection

99 Preoperative Care/Teaching Patient and family teaching Enteral supplements TPN (Total Parenteral Nutrition) Explain the post-op need for drainage tubes, surgical dressings, O2 therapy, IV therapy and pain control Start IV Administer pre-op meds Insert foley catheter Insert NG tube

100 Postoperative Care/Teaching Assess cardiac and respiratory status Assess pain and administer meds as prescribed Inspect surgical site Reinforce turning, coughing and deep breathing Administer IV fluids as prescribed Semi-fowlers position Assess for return of peristalsis

101 Postoperative Care/Teaching Cont. Activity as tolerated Monitor VS, I&O, pulse ox, labs Monitor NG drainage Do not reposition or irrigate NG tube! Weigh patient daily Increase food intake gradually Eat six small meals daily

102 Gastric Cancer Surgical Complications Hemorrhage Infection Dehiscence Disruption in patency of NG tube Dumping syndrome

103 Discharge Health Teaching After??? Gastric Surgery

104 NG Tube Feedings Confirm placement prior to using Maintenance Medications Residuals

105 NG Tube Feedings Nausea, vomiting or bloating: Large residuals- withhold or decrease feedings Medications- review meds and consult MD Rapid infusion rate- decrease rate

106 NG Tube Feedings Diarrhea: Reduce rate Administer at room temperature Constipation: Provide adequate hydration Use formula with fiber

107 NG Tube Feedings Aspiration and gastric reflux: Verify placement Check residuals Keep HOB elevated degrees

108 NG Tube Feedings Occluded tube: Flush more routinely Try to use liquid medications

109 Displaced tube: Re-tape tube Check placement NG Tube Feedings

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