Nutrition in Patients with Gastrointestinal Disorder

The major organs of digestion are those within the gastrointestinal tract (GIT), which begins with the mouth and ends with the anus. The accessory organs or digestion include the liver, gallbladder and pancreas. The digestive system is responsible for digestion (mechanical and chemical) of food, absorption of nutrients and elimination of waste materials.

 Digestive system Organs and their functions

Mouth: beginning of digestion Teeth: bite, crush, and grind food Salivary glands: secrete saliva Esophagus: moves food from mouth to stomach Stomach: churn and mix contents with gastric juices Small intestine: most digestion occurs here Large intestine: forms and expels feces Rectum: expels feces

 Accessory organs of digestion Organs and their functions Liver: produces bile; stores it in the gallbladder Pancreas: produces pancreatic juice Regulation of food intake Hypothalamus One center stimulates eating and another signals to stop eating

Laboratory and Diagnostic Examinations Upper GI series Gastric analysis Esophagogastroduodenoscopy (EGD) Barium swallow Bernstein test Stool for occult blood Sigmoidoscopy Barium enema Colonoscopy Stool culture and sensitivity; stool for ova and parasites Flat plate of the abdomen

 Digestive disorders can be due to structural malfunction, infection, inflammation or disease. The physician who specializes in treating GI disorders is called gastroenterologist. The enterostomal therapist (ET) is a nurse who assists people with learning to care for surgically adapted openings , called ostomies, into the stomach (gastrostomy), intestine (ileostomy) or colon (colostomy)

DIAGNOSTIC TESTS: PLAIN ABDOMEN: Done at random, no dietary

preparation required

BARIUM STUDIES (UPPER AND LOWER GI SERIES)

The patient must understand the appropriate dietary and bowel preparations and should know what the procedure entails. A substance called GOLYTELY is used. It contains electrolytes that cause complete bowel evacuation. The patient is instructed to eat a light supper (some physicians require clear liquids) in the evening and then to be on NPO, except for the bowel prep after supper.

DIAGNOSTIC TESTS: CHOLECYSTOGRAM Patient is instructed to eat a fat-free supper the night before the X-RAY study. Takes a radio opaque dye PO. Eat nothing for the next 12 hours after taking the dye which allows time for the dye to concentrate in the gallbladder. The patient may have water until bedtime then NPO thereafter. OTHER DIAGNOSTIC PROCEDURES: Gastroscopy, ERCP, colonoscopy

COMMON MEDICAL AND SURGICAL TREATMENTS GASTROINTESTINAL INTUBATION Insertion of a tube through the nostrils, mouth or abdominal wall. (NGT, Gastrostomy, jejunostomy. Used for enteral nutrition either short or long duration

ENTERAL NUTRITION: Enteral nutrition also known as tube feedings assists the patient to obtain nutritional intake when he or she is unable to obtain adequate calories, appropriate nutrients, solid foods or liquids by mouth. Patient must have a normally functioning GI tract.

PARENTERAL NUTRITION Parenteral nutrition involves direct IV administration of fluids and nutrients into the circulatory system. This is sometimes referred to as TPN Total Parenteral Nutrition when the nutrient is exclusively given via IV. Parenteral nutrition may be given as TPN or as supplemental. This nutrition provides large quantities of fluids, and nutrients which include proteins, fats, water, electrolytes, vitamins and minerals.

GASTRIC SURGERIES TOTAL OR SUBTOTAL GASTRECTOMY: Surgical procedure to remove part of or the entire stomach Postoperative complications include the development of anemia, such as pernicious anemia or iron deficiency anemia. Electrolyte disturbance may also result from NG suction, malabsorption, diarrhea and vitamin deficiencies.

DUMPING SYNDROME, occurs after gastrectomy and usually develops after overeating or eating foods that are not recommended. There is rapid gastric emptying. Symptoms include borborygmi, palpitation, diaphoresis, faintness, excessive weakness, and diarrhea and/or vomiting. Foods most likely to cause dumping are those foods high in carbohydrates and salt. Food containing MSG, monosodium glutamate is particularly irritating.

DUMPING SYNDROME, Diet - Eat 6 small meals/day - High protein and fat, low in carbohydrates - Eat slowly and avoid fluids during meals - Vitamin B12 for pernicious anemia - Recline for about an hour after meals

Gastroesophageal reflux disease (GERD) Etiology/pathophysiology

Backward flow of stomach acid into the esophagus

Clinical manifestations/assessment
Heartburn (pyrosis) 20 min 2 hrs after eating Regurgitation Dysphagia or odynophagia Eructation

Gastroesophageal reflux disease Diagnostic tests

Esophageal motility and Bernstein tests Barium swallow Endoscopy

Medical management/nursing interventions

Antacids or acid-blocking medications Lifestyle: eliminate smoking, avoid constrictive clothing, HOB up at least 6-8 inches for sleep

GERD

Diet:
- Eat 4-6 small meals/day - Follow a low fat, adequate protein diet - Reduce intake of chocolate, tea and all food and beverage that contain caffeine - Limit or eliminate alcohol intake - Eat slowly and chew food thoroughly - Avoid taking evening snack - Do not eat for 2-3 hours before bedtime - Remain upright for 1-2 hours after eating - Avoid any food that produce heartburn - REDUCE OVERALL BODY WEIGHT

Disorders of the Stomach

Acute gastritis Etiology/pathophysiology
Inflammation of the lining of the stomach May be associated with alcoholism, smoking, and stressful physical problems

Clinical manifestations/assessment
Fever; headache Epigastric pain; nausea and vomiting Coating of the tongue Loss of appetite

Disorders of the Stomach

Acute gastritis (continued) Diagnostic tests
Stool for occult blood; WBC; electrolytes

Medical management/nursing interventions

Antiemetics Antacids Antibiotics IV fluids NG tube and administration of blood, if bleeding NPO until signs and symptoms subside

Disorders of the Stomach

Gastric ulcers and duodenal ulcers
Ulcerations of the mucous membrane or deeper structures of the GI tract Most commonly occur in the stomach and duodenum Result of acid and pepsin imbalances H. pylori Bacterium found in 70% of patients with gastric ulcers and 95% of patients with duodenal ulcers

Disorders of the Stomach

Gastric ulcers (continued)
Etiology/pathophysiology Gastric mucosa are damaged, acid is secreted, mucosa errosion occurs, and an ulcer develops

Duodenal ulcers (continued)

Etiology/pathophysiology Excessive production or release of gastrin, increased sensitivity to gastrin, or decreased ability to buffer the acid secretions

Disorders of the Stomach

Gastric and duodenal ulcers (continued) Clinical manifestations/assessment
Pain: Dull, burning, boring, or gnawing, epigastric Dyspepsia Hematemesis Melena

Diagnostic tests
Esophagogastroduodenoscopy (EGD) Breath test for H. pylori

Fiberoptic endoscopy of the stomach.

Disorders of the Stomach

Gastric and duodenal ulcers (continued) Medical management/nursing interventions Antacids Histamine H2 receptor blockers Proton pump inhibitor Mucosal healing agents Antibiotics

Diet and other interventions: 1. Quit smoking 2. Small frequent meals 3. Avoid high fiber foods 4. Avoid foods rich in sugar, salt and milk 5. Eat slowly and chew food well 6. Avoid caffeine, alcohol, aspirin or any NSAID 7. High in fat and carbohydrates; low in protein and milk products. 8. Bland diet (?)

Cancer of the stomach Etiology/pathophysiology

Most commonly adenocarcinoma Primary location is the pyloric area Risk factors: History of polyps Pernicious anemia Hypochlorhydria Gastrectomy; chronic gastritis; gastric ulcer Diet high in salt, preservatives (nitrites, nitrates), and carbohydrates Diet low in fresh fruits and vegetables

Disorders of the Intestines

Irritable bowel syndrome (IBS) Etiology/pathophysiology
Episodes of alteration in bowel function Spastic and uncoordinated muscle contractions of the colon

Clinical manifestations/assessment
Abdominal pain Frequent bowel movements Sense of incomplete evacuation Flatulence, constipation, and/or diarrhea

 Irritable bowel syndrome (continued)

Diagnostic tests
History and physical examination

Medical management/nursing interventions

Diet and bulking agents Medications Anticholinergics Milk of Magnesia, fiber, or mineral oil Opioids Antianxiety drugs

 Irritable bowel syndrome (continued)

Medical management/nursing interventions Diet and bulking agents:
Adequate fiber is more reliably provided with bulking agents such as Metamucil. The bulking agents seem to be most effective in the treatment of constipationpredominant IBS, although they may alleviate mild diarrhea. If a patient has exacerbation of symptoms after certain foods, those foods should be avoided

Disorders of the Intestines

Ulcerative colitis Etiology/pathophysiology
Ulceration of the mucosa and submucosa of the colon Tiny abscesses form which produce purulent drainage, slough the mucosa, and ulcerations occur

Clinical manifestations/assessment
Diarrheapus and blood; 15-20 stools per day Abdominal cramping Involuntary leakage of stool

 Ulcerative colitis (continued) Diagnostic tests

Barium studies, colonoscopy, stool for occult blood

Medical management/nursing interventions

Medications Azulfidine, Dipentum, Rowasa, corticosteroids, Imodium Stress control Assist patient to find coping mechanisms

 Ulcerative colitis (continued) Medical management/nursing interventions Diet:

- Therapy should exclude milk and products - Avoid highly spiced foods - A high protein, high calorie diet is recommended for people who are nutritionally deficient. - Total parenteral nutrition may be used in severe cases

Disorders of the Intestines

Crohns disease Etiology/pathophysiology
Inflammation, fibrosis, scarring, and thickening of the bowel wall

Clinical manifestations/assessment
Weakness; loss of appetite Diarrhea: 3-4 daily; contain mucus and pus Right lower abdominal pain Steatorrhea Anal fissures and/or fistulas

Disorders of the Intestines

Crohns disease (continued)
Medical management/nursing interventions Medications Corticosteroids Azulfidine Antibiotics Antidiarrheals; antispasmodics Enteric-coated fish oil capsules B12 replacement Surgery Segmental resection of diseased bowel

Crohns disease (continued) Medical management/nursing interventions

Diet:
High-protein (100 g/day) for patients with
hypoproteinemia Elemental diet such as Criticare, Travasorb-HN, and Precision High Nitrogen TPN in severe cases Avoid: Lactose-containing foods, brassica vegetables (cabbage,cauliflower, broccoli, asparagus and brussels sprouts), caffeine, beer, monosodium glutamate, highly seasoned foods, carbonated beverages, fatty foods

Hiatal hernia.
A, Sliding hernia. B, Rolling hernia.

Disorders of the Intestines

Hiatal hernia (continued)
Medical management/nursing interventions Head of bed should be slightly elevated when lying down Surgery Posterior gastropexy Transabdominal fundoplication (Nissen)

Disorders of the Intestines

Intestinal obstruction
Etiology/pathophysiology
Intestinal contents cannot pass through the GI tract Partial or complete Mechanical Non-mechanical

Clinical manifestations/assessment
Vomiting; dehydration Abdominal tenderness and distention Constipation

Figure 5-17

Intestinal obstructions. A, Adhesions. B, Volvulus.

Disorders of the Intestines

Intestinal obstruction (continued)
Diagnostic tests Radiographic examinations BUN, sodium, potassium, hemoglobin, and hematocrit Medical management/nursing interventions Evacuation of intestine NG tube to decompress the bowel Nasointestinal tube with mercury weight Surgery Required for mechanical obstructions

Disorders of the Intestines

Cancer of the colon Etiology/pathophysiology
Malignant neoplasm that invades the epithelium and surrounding tissue of the colon and rectum Second most prevalent internal cancer in the U.S.

Clinical manifestations/assessment
Change in bowel habits; rectal bleeding Abdominal pain, distention and/or ascites Nausea Cachexia

Nursing Process
Nursing diagnoses
Activity intolerance Anxiety Body image, disturbed Constipation Coping, ineffective Diarrhea Fear Fluid volume, deficient, risk for

Home management, impaired Management of therapeutic regimen, ineffective Nutrition, imbalanced: less than body requirements Pain, chronic/acute Skin integrity, risk for impaired Sleep pattern, disturbed Social isolation Tissue perfusion, ineffective

 OK.. DONE, LETS GO HOME!!

Nursing Diagnoses