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CARE OF THE CLIENT WITH

PROBLEMS RELATED TO THE


GASTROINTESTINAL SYSTEM,
LIVER AND BILIARY TREE
ANATOMY AND PHYSIOLOGY

 Major Functions:
2. Ingestion of food
3. Digestion of food
4. Elimination of waste products

 2 Main Groups:
7. Alimentary Canal
8. Accessory Organs
Organs of the Alimentary Canal

MOUTH
also known as ________
_______ protects its anterior opening
_______ protects its lateral walls
_______ forms its anterior roof
_______ forms its posterior roof
_______ fleshy fingerlike projection of the soft
palate
_____ occupies the floor of the mouth
_____ a pair of lymphatic tissue located at posterior
end of the oral cavity
_____ lubricates the food for easy swallowing
PHARYNX
allows the passage of food from the mouth to the
esophagus
ESOPHAGUS
Hollow, muscular tube that propels the food from
the pharynx down to the stomach
STOMACH
A dilated, saclike structure that lies on the left side
of the abdominal cavity nearly hidden by the liver
and diaphragm
Contains 2 important sphincters
The fundus is the expanded part of the stomach
lateral to the cardiac region
 The body is the midportion and the funnel-shaped
pylorus is the terminal part of the stomach
 It has 3 major function such as:
3. Stores food
4. Mixes food with gastric juices
5. Passes chyme
 An average meal can remain in the stomach for 3
to 4 hours
An accordion-like folds in the stomach lining, allows
the stomach to expand when large amount of foods
and fluids are ingested
Chemical breakdown of protein begins in the stomach
SMALL INTESTINE
Considered as the body’s major digestive organ
Longest section of the GI tract and hangs in sausage
like coils in the abdominal cavity
SMALL INTESTINE

 It has 3 sections:
2. Duodenum
3. Jejunum
4. Ileum
 Nearly all food absorption occurs in the small
intestine
LARGE INTESTINE

 It frames the small intestine on three sides and has


the following subdivisions:
2. Cecum
3. Appendix
4. Colon
5. Rectum
6. Anal canal
3 Main functions:
1. Absorbs excess water and electrolytes
2. Stores food residue
3. Eliminate waste products in the form of
feces
ACCESSORY ORGANS

LIVER
Heaviest organ in the body
Located in the right upper quadrant and almost
completely covers the stomach
Has 2 major lobes divided by the falciform ligament
The liver’s function includes
M-etabolism of Carbohydrates, Fats and
Proteins
C-onverts ammonia to urea for excretion
D-etoxify blood
O-synthesizing plasma proteins, nonessential

amino acids
acids, vitamin A and essential nutrients
such as iron, and vitamins D,K, and B12
S-ecretes bile. A greenish fluid that helps
digest fats and absorbs fatty acids,
cholesterol, and other lipids.
GALLBLADDER
Small, pear-shaped organ that lies halfway under the
right lobe of the liver
Its main function is to store bile from the liver until it
is emptied into the duodenum
PANCREAS
Soft, pink, triangular gland that extends across the
abdomen from the spleen to the duodenum
Produces enzymes that digest carbohydrates fats and
proteins (ALT)
BILE DUCTS
Provide the passageways for bile to travel from the
liver to the intestines
2 hepatic ducts drain the liver and 1 cystic duct drains
the gallbladder
METABOLISM

It includes all chemical breakdown and building


reactions needed to maintain life
Carbohydrates are the body’s major energy fuel
Fats insulates the body, protects the organs, build
some cell structure and provide reserve energy
Proteins forms the bulk of the cell structure and most
functional molecules
The liver is the body’s key metabolic organ
 Diagnostic Assessment:
1. Hematologic liver function studies
 To determine excretory function

Serum bilurubin
Serum alkaline phosphatase N=2-5
bodansky unit
SGOT Serum Glutamic Oxalo Transaminase
or AST Aspartate Aminotransferase N= 7-
40 U
SGPT Serum Glatamic Pyruvic
Transaminase or ALT Alanine
Aminotransferase N= 10-40 U
Todetermine metabolic
function
Serum protein- albumin, globulin
Serum ammonia- N= 20-150 ug/
100ml
Serum amylase N= 4-25 u/ml
Prothrombin time N=11-16 secs
 Barium swallow
- identifies structural abnormalities of the
esophagus, stomach, duodenum and
jejunum as well as swallowing
discoordination
Pre-test prep:
2. Low-residue diet several days before the
procedure
3. NPO for 8 to 12 hrs before the test
4. BaSO4 per orem is administered
5. X-rays are taken in standing and lying
positon
 Post-test:
2. Laxative is administered
3. Increase fluid intake
4. Inform patient that the stool is white for 24-72
hours
5. Observe for Barium impaction: abdominal
distention and constipation
Barium Enema

- identifies polyps, tumors, inflammation, strictures


and other abnormalities of the colon
Pre-test prep:
1. Low-residue diet 1 to 2 days before the test
2. Clear liquid diet the evening before the test
3. Laxative is given the evening before the
test
4. NPO after midnight
5. Cleansing enemas the morning of the test ( if not
contraindicated)
6. BaSO4 is administered per rectum
Oral Cholecystography
- identifies stones in the gallbladder or CBD and
tumors or other obstructions
Pre-test prep:
Client swallows 6 dye tablets-one every 5 mins. after
the evening meal with a total of 250 ml of water.
Once the initial x-ray is taken, a fatty test meal is
given to determine GB ability to empty.
Cholangiography

Determines the patency of the ducts from the liver


and gallbladder. It is used when oral
cholycystogram, vomiting interferes with the
retention of the oral dye.
- dye is usually instilled intraveneously (IV)
or through the T-tube surgically placed in
the CBD.
Pre-test prep:
1. Client must sign a consent form
2. Ask if the patient is allergic to iodine or
shellfish.
3. Restrict food and fluids several hrs. before
the examination.
Percutaneous Liver Biopsy

Obtaining a small core of liver tissue by placing


needle (FNB) through the client’s lateral abdominal
wall directly into the liver.
Detects malignancies, infectious and inflammatory
processes, liver damage and sign of rejection post
liver transplant
Pre-test prep:
1. CT scan or ultrasound is done to identify the
appropriate site of the biopsy needle.
2. Position the patient in supine position with a
rolled towel beneath the right lower ribs.
3. Instruct the patient to take a deep breath and hold
it while the needle is being inserted.
 Post-test:
4. Position patient on his right side with a small
pillow under the costal margin for several hrs.
5. Ask the patient to prevent coughing or straining
6. Avoid heavy lifting or strenuous activity post
procedure
Common Gastrointestinal
Endoscopic Procedure

Esophagogastroduodenoscopy (EGD)
- examination of the esophagus, stomach and
duodenum through an endoscope
- local spray anesthetic is given and anxiolytic agent to
provide sedation and relieve anxiety.
Post-test: Nurse monitors for any signs of
complication especially signs of perforation
- may not have food or fluids until the gag reflex
returns.
- Clear fluids are given first then progress to regular
foods according to the client tolerance.
Colonoscopy

Examination of the entire large intestine


with a flexible fiber optic colonoscope
Air maybe instilled to promote visualization
within the folds of the intestinal mucosa
Clients are sedated briefly and monitored
accordingly
Position the patient in knee-chest/lateral
position during the procedure
Proctosigmoidoscopy

Examination of the rectum and sigmoid colon using


a rigid endoscope.
Knee-chest position.
Retrograde Endoscopic
Cholangiopancreatography (ERCP)
Combined endoscopic and radiographic examination
using a contrast radiopaque medium instilled in the
biliary tree and pancreatic ducts.
Periteneoscopy

Examination of GI structures through an endoscope


inserted percutaneously through a small incision in
the abdominal wall
Patient can be given either local, spinal or general
anesthesia
Panendoscopy
Examination of both the upper and lower GI tracts
Stool Analysis

Stools are collected to identify WBC


(inflammation and infection) RBC
(blood loss) and fats (malabsorptions)
 No red meat 3 days prior to collection
of stool.
Gastointestinal Intubation for
Feedings or Medications

 Different Types of GI Intubation


Nasogastric ( nose-stomach via esophagus)
Orogastric ( mouth-stomach)
Nasoenteric ( nose-esophagus-stomach-small
intestine)
Gastrostomy (tube enters the stomach through a
surgically created opening into the abdominal wall.
Jejunostomy (enters jejunum or small intestine)
 Alternative Feeding:
 Enteral hyperalimentation- delivery of
nutrients directly to the GI tract.
 Short- term- esophagostomy; nasogastric tube
 Long- term- gastrostomy; jejunostomy

 Indications of NGT:
1. Gavage- to deliver nutrients; for feeding purposes
2. Lavage- to irrigate the stomach
3. Decompression- to remove stomach contents or air
Types of GI tube

Levin tube – single lumen


Salem-Sump tube - double lumen
Miller-Abbot tube - double lumen
intestinal tube
Cantor-tube - single lumen intestinal tube
Sengstaken-Blakemore tube - triple lumen
tube used to treat bleeding esophageal varices
1. Hang or elevate the feeding bag or syringe about 18
inches above the patient’s head
2. Flush tube with 30-50 ml of water in the end of the
feeding
3. Care of nares with NGT- apply water soluble
lubricant to prevent irritation
4. Reposition tube to ensure patency
5. If tube is for decompression, observe signs and
symptoms for metabolic alkalosis
 Nursing Care in NGT:
Check placement of feeding tube
-Aspirate 10-20 ml of gastric secretions
(measure gastric residual and return to
stomach)
- Measure the pH of aspirated fluid
- Inject 10-30 ml of air into feeding tube and
auscultate over the epigastric area with
stethoscope
 Hyperalimentation (total parenteral
nutrition)- method of giving highly
concentrated solutions intravenously to
maintain a patient’s nutritional balance when
oral or enteral nutrition is possible

 Nursing Management:
 Filter is used in the IV tubing to trap bacteria
 Solution and administration equipment should
be changed every 24 hours
 Dressing changes every 48-72 hrs with
antibiotic ointment to catheter insertion
Medication is never administered in a TPN line
Do not abruptly discontinue TPN
Observe for complications
 Infection

 Venous thrombosis
 Hyperglycemia
 Nursing Assessment
 Anorexia, nausea or vomiting
 Dysphagia
 Dyspepsia (indigestion)
 Pyrosis (heartburn)
 Diarrhea or constipation
 Regurgitation
 Bleeding- hematemesis, melena,
hematochezia,
 flatulence, aerophagia, borborygmus
 Abdominal rigidity
 Hiccup
 Jaundice (obstructive)
 Acholic stools
Common GI Diseases:
Appendicitis

 Inflammation of the verniform appendix


 Predisposing factors:
3. Microbial invasion
4. Fecaliths – undigested food particles
5. Intestinal obstruction
 Nursing Assessment:
7. (+) rebound tenderness
8. Low grade fever
3. anorexia
4. nausea and vomiting
5. pain at the McBurney’s point
 Management:
5. Appendectomy within 24-48 hrs.
6. Medications: antibiotics, antipyretic, no analgesics
7. Avoid heat application, cleansing enema
Nursing Management:

 Post AP
2. FOB for 6-8 hrs (spinal anesthesia)
3. Monitor for return of sensation on lower
extremities
4. NPO until peristalsis returns
5. Encourage ambulation
6. Proper positioning
7. Resume normal activities within 2 to 4 wks.
A. Peptic Ulcer Disease
- break in the continuity of gastric mucosa that
comes in contact with hydrochloric acid and pepsin
 Predisposing Factors
- emotional stress, irregular meals excessive
smoking, drinking coffee or alcohol, drugs;
genetics
Incidence
- more in men with emotional stress; type O blood
 Nursing Management
2. Rest
3. Bland diet- no caffeine, alcohol and spicy
foods
4. Stress nursing management
5. If with hemorrhage- gastric lavage
Gastric Ulcer Duodenal Ulcer
“Poor man’s ulcer” (50 “Executive ulcer” (25 to
y/o and above) 50 y/o)
Incidence: 20% - 80%
Location: Antrum - duodenal bulb
Pain: epigastric,30mins. - mid-epigastric, 3-4
a.c., not relieved by food
and antacids hrs p.c. 12mn-3am,
Weight: loss relieved by food
Hemmorhage: - weight gain
hematemesis - melena
Complication: - perforation
hemmorhage, CA
Medications:
 Antacids-neutralizes hydrochloric acid and relieves pain;
give 1-2 hrs after meals.
Ex. Maalox, Kremil S, Amphogel, Milk of Magnesia
 Anti- ulcer agent- protect ulcers from acid and pepsin.
Given 1 hr before meals (empty stomach)
 H2 (histamine) receptor antagonists- inhibits gastric
secretions; given 1 hour a.c.
Ex. Cimetidine
Ranitidine
Famotidine
 Anticholinergics- decreases motility and volume of gastric
secretions; give 30 min a.c.
 Prostaglandin analogs – used to sustain the mucosal
layer especially those on long treatment with aspirin. Ex.
(Cytotec)
 PPI- Proton Pump Inhibitor- supresses gastric acid by
blocking enzymes associated with the final step of acid
production. Given before meals. Ex.(Losec, Nexium)
 Cytoprotective Drug- coats ulcer, taken on empty
stomach. Ex.(Carafate)
 Helicobacter Pylori Drug- anti-microbials
Ex. (Amoxicillin, Flagyl)
 Anticholinergics- reduce gastric motility and HCL
secretion
Ex. (AtSO4, Bentyl)
Surgery
Gastrectomy- removal of stomach- anastomosis
of esophagus and duodenum
 Billroth I- gastroduodenostomy
 Billroth II- gastrojejunostomy
 Vagotomy- resection of vagus nerve to inhibit vagal
stimulation and decrease motility and gastric secretions
 Pyloroplasty- enlargement of pyloric sphincter to permit
passage
Complication:
Dumping Syndrome
- rapid emptying of food
especially concentrated
carbohydrates in the duodenum;
food draws fluid from the blood
stream- hypovolemia
Signs and Symptoms Nursing Management:
 faintness a. Small frequent meals
 dizziness b. Chew food thoroughly
 sweating c. Avoid high carbohydrate diet
 nausea and d. Avoid liquid within meals
 palpitations e. Lying down after meals-
flat for 5-30min p.c.
Chronic Inflammatory Bowel
Disorders
 Crohn’s Disease  Ulcerative Colitis

- ileum/ascending colon - rectum/lower colon


- unknown, environmental - Unknown, emotional
- 20-30 years, 40-60 years stress
- 15-40 years
- less, stool with pus and - Severe, stool with blood,
mucus pus and mucus

- 5-6 stools/day - 20-30 watery stools/day


Management: TPN, low - Management: Diet-low
fiber, Steroids, Ileostomy fiber, Steroids, TPN,
Ileostomy
Nursing Management of IBD:
a. Pharmacotherapeutics- sulfonamide or
aspirin; corticosteroids; immunosuppressive drugs
b. Diet- cannot cause IBD; for patient comfort
 high calorie and high protein diet
 bland low residue
 limit dairy products
 multivitamin and mineral supplement
 liberal fluid intake of 2.5-3 liters/ day
 TPN
c. Surgery- ileostomy
Colorectal Cancer
 80%- distal portion from sigmoid to anus
 Early detection:
a. digital rectal exam annually after age 40
b. occult blood test yearly after age 50
c. proctosigmoidoscopy every 5 years after age 50

 Signs and symptoms


a. ascending colon- anemia and unexplained GI bleeding
b. descending colon and sigmoid colon- change in bowel
habits and rectal bleeding, tenesmus
Diverticular Disorders

Diverticula – sac or pouches caused by


herniation of the mucosa through a
weakened portion of the intestinal wall
Diverticulosis – multiple outpouchings
Diverticulitis – acute inflammation and
infection caused by fecal material and
bacteria
Management:

1. High fiber diet/low fiber diet


2. Avoid nuts and seeds
3. Bulk-forming laxatives
4. Bed rest
5. Antibiotics, analgesics, anti-cholinergic
6. NGT to relieve distention
7. Weight loss to reduce intra-abdominal pressure
Accessory Organs
Normal and altered liver
function in cirrhosis:
1. Maintenance of normal size and drainage of
blood from gastrointestinal tract- gastrointestinal
symptoms like nausea and vomiting
2. Metabolism of carbohydrates- decreased
energy
3. Metabolism of fats- hepatomegaly (fatty liver);
- decreased energy production; weight loss
 4. Protein metabolism- decreased albumin production-
edema and ascites
- decreased production of clotting factors- bleeding;
anemia
 5. Detoxification of exogenous substances- decreased
metabolism of sex hormones- loss of sex
characteristics;
- decreased metabolism of aldosterone- edema or
ascites;
- increased K or H2 excretion (hypokalemia or
alkalosis);
- decreased metabolism of ammonia- hepatic
encephalopathy
6. Detoxification of exogenous substances- decreased
metabolism of drugs- altered effects, increased toxicity
and side effects
7. Metabolism and storage of vitamins and minerals-
decreased stores of vitamins and minerals- anemia and
decreased energy production
8. Bile production and excretion- obstruction of bile
flow
- decreased Vit. K absorption- decreased clotting
factors- bleeding
9. Bilurubin metabolism- decreased uptake
from circulation- jaundice and pruritus;
- decreased conjugation- increased urine
bilurubin (dark urine);
- decreased GI excretion- acholic stools
Liver Cirrhosis
 Degenerative liver disorder caused by generalized
cellular damage
 Types:
Laennec’s or Alcoholic – results from chronic
alcohol intake and is usually associated with
malnutrition.
Postnecrotic – results from destruction of liver
cells secondary to infection, metabolic liver disease
or exposure to industrial chemicals
Biliary cirrhosis – scarring occurs around the bile
ducts in the liver, usually related to chronic
obstruction
Nursing Assessment:

 Early S/S
2. Weakness and fatigue
3. Anorexia
4. Tea-colored urine, clay-colored stool
5. Loss of axillary and pubic hair
6. Abdominal pain and shortness of breath
7. Skin itching
 Late S/S
2. Nosebleeding, anemia
3. Spider angioma
4. Palmar erythema
5. Gynecomastia and testicular atrophy
6. Ascites and jaundice
 Nursing Management:
2. Provide good nutrition. Vitamins and nutritional
supplements promote healing of liver cells
3. Monitor vital signs for alcohol withdrawal
4. Weight patient daily.
5. Monitor intake and output
6. Give small frequent feedings rather than 3 full
meals
7. Health teaching on abstinence from alcohol
7. Omission of all sedatives (detoxified by
liver)
8. Butter ball diet- foods rich in
carbohydrates are protein sparing
nutrients- they are used by the body for
energy in place of protein
9. Abdominal paracentesis
Complications:

1. Hepatic encephalopathy and coma


2. Portal hypertension- pressure >25-30 cm. of
saline
3. Bleeding esophagastric varices
Nursing Management:
1. IV fluids
2. Antiemetics
3.Blakemore- Sengstaken Tube (esophageal balloon
tamponade)
Nursing Interventions:
a. Keep a pair of scissors at bedside- in the event of
acute respiratory distress cut across tubing to
deflate balloon
b. Deflate esophageal balloon for 5 minutes at 8-10
hrs interval to prevent necrosis
4. Porta- Systemic Shunting
a. Porta caval (portal vein to inferior vena
cava)
b. Splenorenal shunt (splenic to renal)

5. Diet high calorie, low to moderate protein, high


carbohydrate, low fat with vitamins ABCDK
Cholelithiasis- stone formation in the gall bladder
Cholecystitis- inflammation of gall bladder usually
precipitated by gallstones
Choledocholithiasis- stone formation at the
common bile duct

Incidence: (5 F’s)
a. Female
b. Forty (age- 40 years and above)
c. Fair complexion
d. Fertile
e. Fat
Nursing Management:

a. Pain control - Demerol (drug of choice)


b. Anticholinergic - Atropine
c. ESWL Extracorporeal Shock Wave Lithotripsy-
shock waves used to disintegrate gallstones
Pancreatitis
 Inflammation brought about by the digestion of this
organ by the very enzymes it produces
 Nursing Assessment:
- extreme upper abdominal pain
- persistent vomiting
- abdominal distention
- weight loss
- steatorrhea
- elevated serum amylase and lipase
- ecchymosis around umbilicus
- ecchymosis at flank area
Nursing Management:

1. Administer anticholigernics, antacids, pancreatic


extracts. Pancrealipase (Viokase)
2. NPO with NGT in place, no ice chips or hard candies
as these will stimulate the pancreas.
3. IV fluids. May require TPN in moderate or severe
cases
4. Provide Demerol for pain relief
5. Administer fat soluble vitamins
Hepatitis
Inflammatory disease of the liver, usually caused by a virus,
bacteria and toxic injury to the liver
Types of Hepatitis
1. Toxic
2. Viral
Viral Hepatitis
Hepatitis A, B, C
Prevention:
- handwashing
- enteric and blood, body fluids
- do not recap needles
- cannot donate blood
- no intimate sexual contact during period of infection
Pre-icteric (prodromal phase)
- last for 1 week
Assessment :
1. fever and chills
2. nausea and vomiting
3. anorexia
4. hepatomegaly
Icteric Phase
- starts with onset of jaundice
- last from 4 to 6 weeks
Assessment :
- worsening anorexia
- dyspnea
- liver tenderness increases
Post icteric
- begins with disappearance of jaundice, normally lasts
for several weeks up to 4 months
Management:

Promote rest
Maintenance of food and fluid intake
Prevention of injury
Provide comfort