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Digestive Tract: Let’s Get to the Bottom of it. By: Diana Blum RN MSN Metropolitan Community College. Primary Role. Extract molecules essential for cellular function from fluids and food. Ingestion, Digestion, Absorption, Elimination.

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Digestive tract let s get to the bottom of it

Digestive Tract: Let’s Get to the Bottom of it

By: Diana Blum RN MSN

Metropolitan Community College


Primary role
Primary Role

  • Extract molecules essential for cellular function from fluids and food.


Ingestion digestion absorption elimination
Ingestion, Digestion, Absorption, Elimination

  • Digestion: breakdown of food into simple nutrient molecules that can be used by cells

    • Process requires:

      • 1.

      • 2.

      • 3.

http://health.discovery.com/centers/digestive/machine.html


Digestive tract
Digestive tract

  • Also called ___________tract

    • muscular tube about 30 ft long

    • Main parts

      • Mouth

      • Pharynx

      • Esophagus

      • Stomach

      • Small intestine

      • Large intestine

      • Anus


Acessory organs
Acessory Organs

  • Salivary glands

  • Liver

  • Gallbladder

  • Pancreas

  • Each of the above accessory organs secrete fluid that contain special enzymes that enable breakdown (metabolism) of food

  • Peritoneum lines the abdominal cavity and covers surface of organs

    • Enables organs to moves without friction during breathing and digestion


  • Mouth
    mouth

    • Teeth cut and grind food

    • Salivary glands secrete saliva

      • Saliva:

      • Amylase:

    • Tongue mixes saliva with food and when small enough- forces the food into the pharynx


    Pharynx
    Pharynx

    • Shared by digestive and respiratory tracts

    • Joins mouth and nasal passages

    • Contains the epiglottis

      • Covers the airway (like a trap door) to prevent food from entering respiratory tract


    Esophagus
    esophagus

    • Long muscular tube that passes through the diaphragm into the stomach

    • Gravity helps move the food but it is not essential

    • Circular, wave like contractions of the muscles propel food down the tract (peristalsis)


    Stomach
    Stomach

    • Widest section of the GI tract

    • Separated from esophagus by the cardiac sphincter

    • Has 3 sections

    • Unique muscle layers churn food by mixing it with gastric secretions

      • Rennin-starts breakdown of milk proteins

      • Pepsin-partially digests protein

      • HCL acid-partially digests protein

      • Lipase-breaks down fat

    • Chyme:

    • Pyloric sphincter- keeps food in stomach until it is mixed properly


    Small intestine
    Small Intestine

    • Chyme leaves stomach and enters here

    • Chemical digestion and absorption of nutrients take place

    • 20 feet long

    • 3 sections

      • Duodenum-liver and pancreatic enzymes enter here

      • Jejunum

      • Ileum


    Small intestine continued
    Small Intestine Continued

    • Bile- produced in the liver and stored in the GB break down large fat globs

    • Pancreatic enzymes-reduce the fat to glycerol and fatty acids to be easily absorbed

    • 3 layers of tissue make up the wall

      • Mucous membrane-secretes digestive enzymes

      • Sucrase, lactase, maltase, lipase, etc. (see table 36-1)

      • Inner layer- covered with Villi (microscopic projections). Digestive food molecules are absorbed through the villi into the bloodstream

      • Muscle layers continue to contract moving the chyme into the large intestine.


    Large intestine
    Large Intestine

    • No Villi

    • No digestive enzymes

    • Chyme enters through the ileocecal valve

    • Water is absorbed and remaining waste=feces

    • 5 sections

      • Cecum-1st section..appendix is here

      • Ascending colon-up right abdomen

      • Transverse colon- across abdomen just below waist

      • Descending colon-down the left abdomen

        • Sigmoid colon-the part of the descending colon between iliac crest and rectum

    • Rectum-the last 6-8 inches of the large intestine

    • Anus – where waste leaves the body


    Age related changes
    Age related changes

    • Teeth mechanically worn down

    • Illness causes increased risk for problems with digestion/elimination

    • Gingiva recedes

    • Tooth loss from caries and periodontal disease

    • Loss of taste buds

    • Xerostomia (dry mouth) is common

    • Walls of esophagus and stomach are thinner with lessened secretions

    • HCL Acid and digestive enzyme production decreases

    • Gastric motor activity slows

    • Delayed gastric emptying

    • Hunger contractions diminish

    • In the large intestine- muscle layer and mucosa atrophy

    • Smooth muscle tone and blood flow decreases

    • Connective tissue increases

    • Constipation is frequent

    • More laxative use


    Nursing assessment
    Nursing Assessment

    • Hx of illness: weight loss, indigestion, change in bowel habit

    • PMH: surgery, trauma, infection, burns, hepatitis, ulcers, cancer, stomas, meds, allergies

    • Fam Hx: diabetes, CA, ETOH, polyps, obesity, ulcers, GB Dx

    • System Review: flatus, dyspepsia (indigestion), skin changes, caries, diff chewing, abd distention, pain, elimination

    • Functional: nutrition, activity, meal times, likes/dislikes, food beliefs

    • Physical exam: mucous membranes, condition of mouth/teeth, abd distention, bowel tones, palpation, percussion, rectum/anus for lesions, color, hemorrhoids


    Diagnostics
    diagnostics

    • Imaging/radiographs: NPO, allergy (iodine, dye, shellfish), consent

      • UGI

      • Barium swallow/enema

      • Endoscope

        • Upper

        • Lower

    • Hemmocult-looks for blood


    Salem Sump


    Tube feedings
    Tube feedings

    • Assist pt into fowlers to reduce aspiration.

      • Remains this way for 30 minutes after

    • Pt remains up at least 30 degree during continuous feeding

    • Check placement for tube in stomach or duodenum prior to use

      • Air bolus and residual

    • Check to make sure you have the correct formula

    • Stop feeding if nausea or pain

    • Rinse tube with 30 cc fluid after each bolus

    • Administration

      • Remove plunger

      • Pinch tube while inserting syringe to avoid stomach content leak

      • Hold barrel about 12 inches above stomach and allow gravity to infuse

      • Flush after bolus complete


    Gi decompression
    GI decompression

    • Ng with suction

      • removes fluid and gas

    • To use

      • Attach to sxn as ordered

        • Generally low, intermittent is used for single tube

        • Low continuous for dual lumen tubes

      • Check patency

      • Irrigate routinely

      • Monitor output

      • Assess for flatus

      • Provide comfort measures

      • Once tube in place- securely tape it to nose


    Feedings

    TPN

    Deliver nutrients directly into bloodstream via central line

    Use sterile technique for dressings and care

    Monitor flow rate

    Monitor blood glucose

    Label lines

    PPN

    Same as TPN except goes through peripheral line

    feedings


    Anorexia
    Anorexia

    • Lack of appetite

    • Causes

      • Nausea

      • Physical/emotional disturbances

      • Environment

      • Decreased sense of smell

    • Tests: weight, physical, hemoglobin, iron, electrolytes, thyroid


    Nursing diagnosis
    Nursing diagnosis

    • Imbalanced nutrition less than requirements r/t anorexia

    • Goal: improved appetite and adequate food intake

    • AEB: increase in intake, stable or increased wt

    • Interventions: provide antiemetics prior to meals, remove the bed pan and emesis basin from sight, conceal drains and collection devices, deodorize room


    Clients with feed problems
    clients with Feed problems

    • Paralyzed

    • Confused

    • Severe arthritis

    • CVA

    • Visually impaired

    • Etc

    • FEEDER is demeaning and can threaten self esteem


    Interventions for feed problem
    Interventions for feed problem

    • Position properly

    • Specially enhanced utensils

    • Open sealed products

    • Cut meats

    • Butter bread

    • Season food after asking client their preferences

    • See page 751


    Role play
    Role play

    Practice feeding classmate a simple meal then reverse.

    The person being fed can not speak but understands what is being said

    1.How did it feel to be fed?

    2. What steps did you use?

    3. How did the feeder feed?

    4. What did you learn?


    Stomatitis
    Stomatitis

    • Inflammation of the oral mucosa

      • Mechanical trauma (poor fitting dentures)

      • Irritation 2nd to smoke and ETOH

      • Poor hygiene

      • Radiation

      • Drug therapy

        Treatment: soft bland diet, antiviral agents, antibiotics


    Vincent s infection aka trench mouth
    Vincent’s infection (aka Trench Mouth)


    Vincent s infection
    Vincent’s infection

    • Caused by bacteria

    • Called trench mouth b/c occurred in WWI field

    • S/S: metallic taste foul breath. Bleeding ulcers, increased saliva, general infection signs, anorexia

    • TX: topical antibiotics, mouthwash, rest, nutritious diet, good oral hygiene



    Herpes simplex1
    Herpes Simplex

    • Caused by Herpes simplex virus type 1

    • S/S: ulcers and vesicles in mouth and on lips

    • Other name is cold sore or fever blister

    • Common with people who have upper respiratory infections, excessive sun exposure, or are stressed

    • TX: Camphor, topical steroids, antiviral agents


    Aphthous stomatitis aka canker sore
    Aphthous Stomatitis (aka canker sore)

    • Caused by virus

    • S/S: ulcer on lips or mouth that recur at intervals

    • TX:topical or systemic steroids


    Candidas albicans aka yeast like fungus
    Candidas AlbicansAKA yeast like fungus

    • Other names: thrush or candidiasis

    • S/S: bluish white lesions on mucous membrane of mouth

    • Those at risk: steroid users, long term antibiotic users

    • TX: oral medications, topical antifungal agents, vaginal nystatin tablets can be used like lozenges


    Care and intervention

    CARE

    Usually tx outpt

    Look at pt symptoms

    Onset of symptoms, meds, radiation, habits, diet, ETOH use, and smoking

    Describe pain (location, onset, precipitating factors)

    INTERVENTION

    Gentle oral hygiene

    Prescribed mouthwash

    Use soft bristle tooth brush

    Instruct to take meds as prescribed (swish and spit, or swish and swallow)

    Teach flossing techniques

    Care and intervention


    Dental caries
    Dental Caries

    • Destructive process of tooth decay

    • Caused by plaque

      • Plaque is made from bacteria, saliva, and cells that stick to tooth surface

    • In time if untreated the canal will erode causing intense pain and death of pulp

    • TX: fluoride, good nutrition


    Gingivitis
    Gingivitis

    • Beginning of periodontal dx

    • Inflammation of the gums

    • s/s: red inflammed tissue of gums, pain, bleeds easily

    • More frequent in those with missing teeth or whose teeth don’t close properly, vitamin deficiency, anemia


    Care and intervention1

    CARE

    Assess pain and soreness

    Assess diet and examinations

    Examine mouth care practices

    INTERVENTION

    Minimize pain

    Gentle mouth care several times a day

    Teach client proper technique

    Page 752

    Care and Intervention


    Oral cancer
    Oral Cancer

    • Most life threatening condition of mouth

    • 2 types:

      • Squamous

      • Basal cell

    • S/S: tongue irritation, loose teeth, tongue pain, ulcerations, leukoplakia (hard white spots), decreased appetite, diff swallowing, weight loss, change in denture fit, hemoptysis

    • TX: biopsy, surgery, radiation, chemo


    Care and intervention2

    CARE

    Assess sun exposure, smoking habits, ETOH use, fam hx of oral ca,

    Interventions

    Radiation=edema

    Dry mouth is issue

    Good hygiene

    Special rinses see pg 753

    Monitor respirations

    Suction if ordered

    Stay on top of pain

    Soft or liquid diet

    Monitor I/O

    Use communication board to talk with pt

    BE PATIENT

    BE A GOOD LISTENER

    Monitor for infection

    If graft: monitor color and temp

    Care and Intervention


    Parotitis
    Parotitis

    • Inflamed parotid glands

    • S/S: painful swelling near low jaw, pain increases with mastication

    • Suseptible: those unable to drink liquids, those weak, no resistance to infection

    • TX: antibiotics, mouthwash, warm compress

    • Complications: gland ruptures, surgical drainage or removal may be necessary


    Achalasia
    Achalasia

    • Progressive worsening dysphagia

    • Low esophageal muscles do not relax

    • Unknown cause

    • TX:dilation, surgery, botulism toxin, isosorbide dinitrate


    Esphageal cancer
    Esphageal cancer

    • Not common

    • Poor prognosis

    • No known cause

    • At risk: smokers, ETOH users, chronic trauma, poor oral hygiene, spicy food eaters

    • S/S: progressive dysphagia, substernal pain, epigastric pain, neck/back pain,sore throats, choking, obstruction, weight loss


    Esophageal treatment
    Esophageal treatment

    • Esophagectomy

    • Esophagogastrostomy

    • Esophagoenterostomy

    • Dilitation of esophagus

    • Stent

    • Laser tx

    • Chemo

    • Radiation

    • Photodynamic therapy

    • See page 756


    Interventions
    Interventions

    • Treat pain

    • Daily weight

    • Strict I/O

    • Calorie count

    • Quiet relaxed environment

    • Erect position

    • Chin tuck maneuvers for swallowing

    • Feeding tubes

    • TPN

    • If post op---do not irrigate or reposition

    • Assess pt knowledge

    • Monitor for infection

    • Monitor respirations


    N/V

    • Nausea: feeling of queasiness

      • Pain, pallor, perspiration, cold, clammy skin

      • Causes: irritating foods, infection, radiation, meds, inner ear disorders, motion sick

    • Vomiting: forceful expulsion of stomach content through the mouth

    • Regurgitation: gentle ejection of fluid or food w/o nausea or retching

    • TACHYCARDIA AND INCREASED SALIVA are common before vomiting

    • Complications: loss of fluid and electrolytes, dehydration, metabolic alkalosis, weakness, aspiration

    • TX: antiemetics, iv fluids, NG tube

    • Interventions: maintain cool room, remove unpleasant stimuli, place in comfortable position, provide emesis basin, cool damp cloth on head/neck, slow deep breaths, offer mouth care after vomiting, clear liquids


    Hiatal hernia
    Hiatal Hernia

    • Protrusion of stomach and and lower esophagus up thru the diaphragm and into chest

    • 2 types:

      • Sliding: gastroesophageal junction is just above the hiatus. Stomach slides when patient reclines (associated with GERD)

      • Rolling: gastroesophageal junction remains in place but a portion of the stomach herniates up throu diaphragm through a 2nd ary opening

    • Complications: ulcerations, bleeding, aspiration

    • Strangulated hernia is one that becomes trapped without blood flow

    • Causes: asymptomatic to fullness, dysphagia, eructation (belching), regurgitation, heartburn

    • TX: meds(antacids, H2 receptor blockers, etc), diet, avoid intra abd pressure, surgery

    • Interventions: stay on top of pain, no food or fluid 2-3 hours before bed, wooden blocks under top of bed, monitor wt, small frequent meals, avoid fatty foods, caffeine, ETOH, and spicy foods


    GERD

    • Back flow of gastric content from the stomach into the esophagus

    • Key find: inappropriate relaxation of the low esophagus sphincter

    • Causes: abnormalities in the LES, ulcers, esophageal surgery, prolonged vomiting, gastric intubation

    • S/S: can be sudden or gradual, painful burning that moves up and down (common after meals) resolve after antacids, dysphagia, belching

    • Diagnosis: Based on s/s, raqdiographic studies, endoscopy, bx

    • Tx: H2 receptor blockers (zantac), prokinetic agents (reglan), proton pump inhibitors (prilosec), surgery


    Gastritis
    Gastritis

    • Inflammation of the stomach lining

    • Mucosal barrier that normally protects stomach breaks down

    • H pylori is cause

    • S/S: N/V, anorexia, fullness, pain, hemorrhage

    • Tx: npo until resolve, IVF, Bx, medication,, bland diet, surgery


    Peptic ulcer
    Peptic Ulcer

    • Loss of tissue from digestive lining

    • Caused by pepsin and HCL injure unprotected tissue

    • LOCATION, LOCATION, LOCATION

      • Either gastric or duodenal

    • Causes: drugs, infection, stress.

    • S/S: burning pain, nausea, anorexia, wt loss

    • Complication: hemorrhage, perforation, obstruction,

    • Tx: meds, diet, stress management


    • Drug therapy

      • Used to relieve symptoms

      • Antacids are first line of defense

    • Diet

      • Avoid coffee, tea, meat broth, alcohol, spicy food

      • Frequent small feedings

    • Management

      • NG tube to sxn if hemorrhage suspected

      • Saline lavage after NG procedure on page 769-772

      • Vasopressin may help control hemorrage



    Stomach cancer
    Stomach cancer

    • 25,000 dx each year

    • Most common in men, african americans, people over 70, low socioeconomic status

    • S/S: no early signs

    • Late signs: vomiting, ascites, liver enlargement, abd mass

    • 5 yr survival: 10%

    • No known cause

    • Risk factors: pernicious anemia, chronic atrophic gastritis, achlorhydria (lack of HCL), smoking, high salt starch pickled food nitrate diet


    Obesity
    obesity

    • Excess body fat

    • Causes: heredity, body build, metabolism, psychosocial, caloric intake

    • Complications: heart/lung problems, DM, polycythemia, cholelithiasis, infertility, endometrial cancer, DJD

    • Tx: wt reduction diet, exercise, medication (pg775), surgery,


    Malabsorption
    malabsorption

    • 1 or more nutrients not absorbed/digested

    • Causes: bacteria, bile salt and digestive enzyme deficiency, alterations in intestinal mucosa

    • 2 types:

      • Celiac sprue (tropical, nontropical)- genetic,

        • Non-Tropical: changes in mucosa, impaired absorption

        • Tropical: infectious agent

      • Lactose intolerance

        • Inherited or aquired

        • Causes: IBS, gastroenteritis, sprue syndrome

    • S/S: steatorrhea (fatty stools), foul stools, wt loss, decreased libido, easy bruising, edema, anemia, bone pain

    • Tx: diet, meds, elimate gluten for celiac dx

      • Tropical sprue: oral folate, antibx, vit B12 injections

      • Lactose: no milk or milk products, lactase enzyme, monitor vitamin levels


    Diarrhea
    diarrhea

    • Loose liquid stools

    • Causes: spoiled foods, allergies, infection, diverticulosis, cancer, malabsorption, impactions, tube feedings, medications

    • S/S:cramps, abd pain, urgency

    • Complications: dehydration, electrolyte imbalance

    • Tx: anti diarrheal drugs, clear liquids vs npo, possible TPN


    Constipation
    constipation

    • Hard dry infrequent stools

    • Causes: ignoring urge, laxative use, inactivity, inadequate fluid intake, drugs, brain/spinal cord injury, colon diseases, surgery,

    • Tx: laxatives, stool softeners,


    Megacolon
    megacolon

    • Large intestine looses ability to contract to move feces to rectum

    • Pts need regular enemas


    Fecal impaction
    Fecal impaction

    • Retention of large amount of stool in the rectum

    • Some liquid passes around

    • TX: Digital exam/extraction


    Intestinal obstruction
    Intestinal obstruction

    • Causes by strangulated hernia, tumor, ileus, stricture, volvulus (twisting of bowel)

    • S/S: vomiting (bile, blood, feces), abd pain, constipation

    • Complications: electrolyte imbalances, gangrene, perforation, shock, death

    • TX: gastric decompression, IVF, surgery


    Appendicitis
    appendicitis

    • Blind patch in the cecum

    • Inflammation of opening of appendix-bacteria related

    • s/s: pain especially at mcburney’s point (1/2 way b/w umbilicus and iliac crest), fever, n/v, elevated WBC

    • Tx: NPO, cold pack


    Peritonitis
    peritonitis

    • stomach contents enter Abd cavity

    • Complications: fluid shift, abscesses, adhesions, septicemia, hyovolemic shock, ileus, organ failure

    • S/S: abd distention, increased pulse and RR, n/v, fever, rigid abd, shock

    • TX: NG for gastric decompression, IVF, antibiotics, pain meds, surgery


    IBS

    • 2 types:

      • Ulcerative colitis:

        • Begins in rectum, expands to cecum

      • Crohn’s: regional enteritis

        • Affects all GI tract

        • Most common= terminal ileum

    • Causes: unknown

    • S/S of IBS: constipation, diarrhea, bloody stools, abd cramping, wt loss

    • S/S crohn’s: variable, n/v, pain, cramping, abd tenderness, fever, night sweats, malaise, joint pain

    • Complications:hemorrhage, obstruction, perforation, abscess, fistulas, megacolon, colon cancer, joint inflammation, diarrhea, stones, liver dx, electrolyte imbalances

    • Tx: meds (page 786), low roughage diet without milk, nicotine patches, surgery with possible removal of intestine


    Diverticulosis
    Diverticulosis

    • Small sac like pouches in intestinal wall

    • Most in sigmoid colon

    • Risk factors: lack of dietary factors, age, constipation, obesity, emotional tension

    • S/S: asymptomatic, constipation, diarrhea, pain, rectal bleed, n/v, urinary problems

    • Complications: bleed, obstruct, perforation, peritonitis, fistula

    • Tx: high residue diet, no spicy foods, no seedy food, stool softener, meds, page 788, surgery


    Colorectal ca
    Colorectal CA

    • 3rd most common in women

    • High fat low fiber diet is risk factor

    • Most found in rectum or low sigmoid

    • S/S: depend on location, cramping, anemia, weakness, fatigue, left sided= more obvious changes

    • TX: surgery, colostomy, chemo, radiation


    Polyps
    Polyps

    • Small benign growths that can become malignant

    • Multiple polyps called gardner’s syndrome or familial polyposis

    • S/S:asymptomatic

    • Complications: bleed, obstruction

    • Tx: removal, colectomy


    Hemorrhoids
    hemorrhoids

    • Dilated veins in rectum

    • May be internal or external

    • Risk factors: increased pressure in rectal blood vessels from constipation, pregnancy, prolonged sit or stand

    • S/S: pain, bleed, itching,

    • TX : surgery, ice followed by heat, medication


    Anorectal abscess
    Anorectal abscess

    • Infection in the tissue around rectum

    • S/S: pain, swelling, redness, tenderness, diarrhea, bleeding, itching, discharge

    • Tx: antibx, incision, drainage, surgery, ice packs, pt education r/t to cleansing


    Anal fissure
    Anal fissure

    • Laceration b/w anus and perianal skin

    • r/t constipation, diarrhea, crohn’s, TB, leukemia, trauma, childbirth

    • S/S: pain with defecation, bleeding, itching, urinary frequency, urinary retention, dysuria

    • Tx: heal spontaneously, sitz bath, stool softeners, pain meds, surgery


    Anal fistula
    Anal fistula

    • Abnormal opening b/w anal canal and perianal skin

    • Causes: abscess, IBD, TB

    • S/S: pruritis, discharge

    • Tx: sitz bath, surgery, temporary colostomy, pain meds


    Pilonidal cyst
    Pilonidal cyst

    • Painful and swollen

    • May form abscess

    • Surgery may be needed to fix


    Pt education
    PT EDUCATION

    • Handwashing

    • Proper food handling

    • Food poisoning

    • Stress management

    • When to call doctor

    • Page 793



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