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The Gastrointestinal System

20Lecture Note PowerPoint Presentation

Gerontological Nursing, Second EditionPatricia A. Tabloski

LEARNING OUTCOME 1Describe age-related changes that affect

gastrointestinal function.

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GASTROINTESTINAL CHANGES ASSOCIATED WITH AGING Begin before age 50

Changes in the mouth Decreased esophageal motility Reduced peristalsis Diminished ability of gastric mucosa to resist damage Decreased production of intrinsic factor Reduced intestinal absorption and blood flow Intrinsic factor (IF) also known as gastric intrinsic factor (GIF) is a

glycoprotein produced by the parietal cells of the stomach. It is necessary for the absorption of vitamin B12 later on in the terminal ileum

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http://en.wikipedia.org/wiki/Glycoprotein

http://en.wikipedia.org/wiki/Parietal_cell

http://en.wikipedia.org/wiki/Stomach

http://en.wikipedia.org/wiki/Vitamin_B12

http://en.wikipedia.org/wiki/Vitamin_B12

http://en.wikipedia.org/wiki/Terminal_ileum


FIGURE 20-1NORMAL CONFIGURATION OF THE GI TRACT.

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GASTROINTESTINAL CHANGES ASSOCIATED WITH AGING Begin before age 50

Decreased pancreas size Increased incidence of cholelithiasis, decreased

production of bile synthesis Decreased liver size and blood flow Decreased thirst and hunger Increased medication use

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LEARNING OUTCOME 2Describe the impact of age-related changes of

gastrointestinal function.

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AGING AND THE GASTROINTESTINAL SYSTEM Aging has limited impact on system Aging associated with increased prevalence

of many GI disorders Evaluate disorders closely

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FIGURE 20-2NORMAL CHANGES OF AGING RELATED TO THE GASTROINTESTINAL TRACT.

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DYSPHAGIA Number-one esophageal disorder in older

people Impacts oral intake Seen in 50% of institutionalized persons

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DYSPHAGIA Causes

Poor tongue control Poor preparation of food bolus for swallowing Poor dentition: pertains to the development of

teeth and their arrangement in the mouth Lack of saliva

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DYSPHAGIA Signs and symptoms

Reports of difficulty swallowing Difficulty controlling food or saliva in mouth Facial droop Dementia, frailty, confusion Inability to sit upright

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DYSPHAGIA Signs and symptoms

Choking or coughing while eating Increased oral or nasal congestion after meals Weak voice or slurred speech Recurrent upper respiratory infections Unexplained weight loss

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DYSPHAGIA Risk factors

Incorrect positioning Inappropriate intake Rapid feeding Older persons labeled as “difficult”

Comorbidities Neurological disorders Muscular disorders Anatomical abnormalities

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DYSPHAGIA Nursing assessment

Observation of individual during eating and drinking

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DYSPHAGIA Nursing assessment

Question patient concerning Choking Dry mouth Excess saliva Inability to control food in mouth Spitting up after meals Need to frequently clear throat Difficulty sitting up during mealtimes

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DYSPHAGIA Nursing interventions

Minimize distractions while eating Use consistent feeding techniques Proper positioning during mealtime Monitor respirations during feeding Provide oral hygiene before and after eating Offer intake consistencies as recommended Do not forcefully feed

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GASTROESOPHAGEAL REFLUX DISEASE Caused by weakness of esophageal sphincter Increased incidence of hiatal hernia Risk factors

Aging Thyroid disease Scleroderma or connective tissue disorders Diabetes

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GASTROESOPHAGEAL REFLUX DISEASE Risk factors

Aging Thyroid disease Scleroderma or connective tissue disorders Diabetes

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GASTROESOPHAGEAL REFLUX DISEASE Signs and symptoms

Heartburn Indigestion Belching:(also known as burping, ructus, or eructation)

involves the release of gas from the digestive tract (mainly esophagus and stomach) through the mouth.

Hiccups Regurgitation of gastric contents Voice hoarseness

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http://en.wikipedia.org/wiki/Gas

http://en.wikipedia.org/wiki/Esophagus

http://en.wikipedia.org/wiki/Stomach

http://en.wikipedia.org/wiki/Mouth


GASTROESOPHAGEAL REFLUX DISEASE Triggers

Eating large meals Certain medications High-fat foods High caffeine intake Alcohol and tobacco use Reclining after eating Obesity

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GASTROESOPHAGEAL REFLUX DISEASE Consequences for GERD Nursing assessment of GERD Diagnostic testing

Barium swallow Endoscopy Esophageal contents pH

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GASTROESOPHAGEAL REFLUX DISEASE Goals of treatment

Symptom control Heal mucosal injury

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GASTROESOPHAGEAL REFLUX DISEASE Lifestyle modifications

Elevate head of bed Reduce portion size Avoid trigger foods Drink 6 to 8 ounces of water with medications

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GASTROESOPHAGEAL REFLUX DISEASE Lifestyle modifications

Report all medications to physician Avoid tight-fitting clothes and girdles(belt-shaped

textile) Remain upright after meals for 1 to 3 hours Avoid right side-lying position Stop smoking

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GASTROESOPHAGEAL REFLUX DISEASE Medications

Antacids Aluminum-containing antacids Histamine 2 receptor agonists Proton pump inhibitors Combination drugs

Surgery

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GASTRIC DISORDERS Gastritis

Inflammation of the gastric mucosa Classification

Severity Site involvement Inflammatory cell type

Diagnosis Endoscopy

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GASTRIC DISORDERS Gastritis

Treatment Reducing contributing factors Acid neutralization and suppression Protection of gastric mucosa Antibiotic therapy Transfusions as needed

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GASTRIC DISORDERS Peptic and duodenal ulcer disease

An excoriated area of the gastric mucosa Signs and symptoms

Bleeding Positive fecal occult blood test Pain

Diagnosis H. pylori breath test Endoscopy

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GASTRIC DISORDERS Peptic and duodenal ulcer disease

Treatment Discontinue use of NSAIDs, alcohol, tobacco, and

caffeine Small, frequent meals Medications

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GASTRIC DISORDERS Zollinger-Ellison syndrome

Caused by a gastrin-producing tumor Characterized by gastric hypersecretion and

peptic ulceration Treatment may include tumor removal and

surgical resection

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GASTRIC DISORDERS Gastric volvulus

Turning, twisting, or telescoping of the stomach onto or into itself

Symptoms Acute pain Shock and hypotension Abdominal distention Inability to vomit Dyspnea

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LOWER GASTROINTESTINAL TRACT DISORDERS Diverticular disease

Saclike mucosal projections protrude through muscular layer of GI tract

Projections may trap feces resulting in inflammation, infection, and rupture

Seen most in sigmoid and descending colon

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LOWER GASTROINTESTINAL TRACT DISORDERS Diverticular disease

Risk factors Physical inactivity Constipation Obesity Smoking NSAID therapy

Management Increase fiber intake

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LOWER GASTROINTESTINAL TRACT DISORDERS Diverticulitis

Normal bowel flora and fecal material becomes trapped in pouches resulting in inflammation, infection, and obstruction

Signs and symptoms Fever Leukocytosis Pain or abdominal tenderness

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LOWER GASTROINTESTINAL TRACT DISORDERS Assessment of diverticular disease

Physical examination Questions regarding bowel history

Diagnosis Abdominal CT scan Ultrasound

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LOWER GASTROINTESTINAL TRACT DISORDERS Goals of treatment

Eliminate bacterial infection Liquid diet advancing to low fiber to allow colon

to rest

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INFLAMMATORY BOWEL DISEASE Ulcerative colitis

Chronic inflammatory process Impacts superficial layers of colon walls Wide spread ulceration of colon walls Signs and symptoms

Bloody diarrhea Lower left quadrant abdominal pain Weight loss

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INFLAMMATORY BOWEL DISEASE Ulcerative colitis

Diagnosis Sigmoidoscopy Colonoscopy Rectal mucosa biopsy Stool specimens

Treatment Oral corticosteroids 5-ASA drugs Surgery

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INFLAMMATORY BOWEL DISEASE Crohn’s disease

Chronic inflammatory disorder of the terminal ileum or colon

Characterized by inflammation, linear ulcerations, and granulomas

Signs and symptoms Diarrhea Fever Abdominal pain Weight loss

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INFLAMMATORY BOWEL DISEASE Crohn’s disease

Diagnosis Abdominal CT scan Complete blood cell count Barium enema colonoscopy

Treatment Oral corticosteroids Surgery

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BENIGN AND MALIGNANT TUMORS Benign tumors or polyps seen in 75% of

persons over age 50 Predisposing factors

Age Diet Family history Prior diagnosis polyps

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BENIGN AND MALIGNANT TUMORS Malignant tumor

2nd most common malignancy in the United States

Increase incidence with age Predisposing factors

Family history Inflammatory bowel disease History of colorectal tumors

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Signs and symptoms Change in bowel habits Abdominal pain Abdominal mass Anemia Rectal bleeding Weight loss

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Diagnostic testing Colonoscopy Carcinoembryonic antigen levels Sigmoidoscopy Fecal occult blood testing

Treatment Surgical resection

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ANTIBIOTIC THERAPY ASSOCIATED DIARRHEA AND COLITIS Occurs during or shortly after administration

of antibiotics Caused by Clostridium difficile cytoxin,

causing bowel inflammation and epithelial necrosis resulting in diarrhea and postmembranous colitis

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ANTIBIOTIC THERAPY ASSOCIATED DIARRHEA AND COLITIS Signs and symptoms

Watery, nonbloody diarrhea Low abdominal pain Fever

Potential complications Dehydration Hypotension Colonic perforation

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ANTIBIOTIC THERAPY ASSOCIATED DIARRHEA AND COLITIS Diagnosis

Stool perforation Treatment

Metronidazole Vancomycin

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CONSTIPATION Definitions

Infrequent defecation Hardened or reduced caliber of stool Sensation of incomplete evacuation or need to

strain with stools Three bowel movements or less per week

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CONSTIPATION Predisposing factors

Aging Certain medications Metabolic and endocrine disorders Muscular dystrophy Neurologic disorders Recent abdominal surgery Obstructive disorders

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CONSTIPATION Complications

Abdominal discomfort Loss of appetite Nausea and vomiting Excessive straining

Hemorrhoids, anal fissures, and rectal prolapse Intestinal obstruction Colonic ulceration Overflow incontinence with stool leakage

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CONSTIPATION Assessment

Evaluate complaint Management

Education Hydration Increased mobility Fiber supplementation

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CONSTIPATION Assessment

Management Medication

Bulk laxative Stool softeners Osmotic laxatives Magnesium containing laxatives Senna Suppositories and enema

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DIARRHEA Defined as abnormally loose stool

accompanied by change in frequency or volume

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DIARRHEA Causes

Virus Food poisoning Food contamination Medications Lactose intolerance

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DIARRHEA Symptoms

Urgency Cramping Bloating Incontinence Pain on defecation Presence of blood in stool

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DIARRHEA Assessment

Interview Physical examination

Management Antidiarrheal agents Soluble fiber

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FECAL INCONTINENCE Seen in 50% of institutionalized elderly Cause

Mobility problems Severe depression Cognitive impairment

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HEMORRHOIDS AND RECTAL BLEEDING Hemorrhoids and colorectal cancer most

common causes of rectal bleeding Hemorrhoids are varicose of anorectal

junction Treatment based upon size

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LIVER AND BILIARY DISORDERS Signs and symptoms

Older adults often present with vague, ambiguous symptoms

Fatigue Weight loss Anorexia Malaise

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LIVER AND BILIARY DISORDERS Risk of disease increases with aging Hepatitis A Hepatitis B Hepatitis B and C Hepatic cysts

Common in older adults Typically benign

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LIVER AND BILIARY DISORDERS Hepatic cysts

Common in older adults Typically benign

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LIVER AND BILIARY DISORDERS Metastatic carcinoma

Most common liver cancer Highest rates in those aged 50–70 Associated with alcohol and tobacco use

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Signs and symptoms Jaundice Variceal bleeding Ascites Right upper quadrant pain Weight loss Enlarged liver

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Diagnostic tests Liver function tests Abdominal ultrasound CT scan Liver biopsy

Treatment based upon tumor stage and patient’s health status

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LIVER AND BILIARY DISORDERS Gallstones

Increased incidence with age 1:3 people over age 70 have gallstones Symptoms

Right upper quadrant pain Gas Distention Nausea and vomiting

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LIVER AND BILIARY DISORDERS Gallstones

Diagnostic testing Abdominal CT scan Ultrasound

Treatment Laparoscopic cholecystectomy Pharmacological dissolution Extracorporeal shock wave lithotripsy Dietary modifications

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LIVER AND BILIARY DISORDERS Pancreatitis

Acute pancreatitis Symptoms

Epigastric pain Nausea and vomiting Elevated serum liver function studies

Amylase Lipase Bilirubin Alkaline phosphatase

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Acute pancreatitis Treatment

Nasogastric suction Pain management Hyperalimentation Fluid replacement

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Chronic pancreatitis Symptoms

Weight loss Diarrhea Diabetes Persistent pain

Treatment Behavior modification Surgery

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LEARNING OUTCOME 3Identify risk factors to health for the older person

with gastrointestinal problems.

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MEDICATIONS WITH POTENTIAL TO AFFECT THE GASTROINTESTINAL TRACT Anticholinergics

Antidepressants Neuroleptics Antihistamines Antiparkinsonian agents

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MEDICATIONS WITH POTENTIAL TO AFFECT THE GASTROINTESTINAL TRACT Antihypertensives

Calcium channel blockers ACE inhibitors Diuretics

Iron and calcium supplements Aluminum-containing antacids Opiates Laxatives

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MEDICATIONS AS RISK FACTORS FOR ESOPHAGEAL INJURY Nonsteroidal anti-inflammatory drugs

(NSAIDs) Potassium chloride Tetracycline Quinidine Alendronate Ferrous sulfate Theophylline

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RISK FACTORS FOR DYSPHAGIA IN INSTITUTIONALIZED OLDER PERSONS Inappropriate positioning for mealtimes Inappropriate feeding of foods and liquids

Thin food and liquids difficult to swallow Thickened liquids slow the swallow process

Too-rapid feeding of at-risk patients Residents labeled as “difficult” or

“uncooperative”

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GERD RISK FACTORS Primary

Length and frequency of esophageal acid exposure

Others Thyroid disease Diabetes Scleroderma Connective tissue disorders

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RISK FACTORS FOR LARGER ULCERS Higher doses of NSAIDs History of peptic ulcer disease Concurrent use of anticoagulants

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LIFESTYLE FACTORS CONTRIBUTE TO RISK OF DIVERTICULOSIS Inadequate dietary fiber intake

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PREDISPOSING FACTORS FOR BENIGN TUMORS Age Diet Family history Prior diagnosis of polyps

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C. DIFFICILE-INDUCED DIARRHEA AND COLITIS Recent surgery Nasogastric or gastric intubation Antibiotics Common in older persons receiving

treatment in hospitals or residing in nursing homes

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DRUGS COMMONLY ASSOCIATED WITH DIARRHEA Nonsteroidal anti-inflammatory drugs

(NSAIDs) Magnesium-containing antacids Antiarrhythmics Beta-blockers Quindine Colchicines Digoxin

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RISK FACTORS FOR CONSTIPATION Dehydration Side effects of medications

Anticholinergic side effects Antidepressants Neuroleptics Antihistamines Antiparkinsonian agents

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RISK FACTORS FOR CONSTIPATION Side effects of medications

Selected antihypertensive agents Calcium channel blockers ACE inhibitors Diuretics

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RISK FACTORS FOR CONSTIPATION Side effects of medications

Iron supplements Calcium supplements Aluminum-containing antacids Benzodiazepines Antiarrhythmics Opiates

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RISK FACTORS FOR CONSTIPATION Insufficient fiber intake Cognitive impairment and immobility Physical illness

Metabolic/endocrine disorders Muscular dystrophy Neurological disorders Recent abdominal surgery Obstructive disorders

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RISK FACTORS FOR FECAL INCONTINENCE Dementia Depression Chronic pain Lack of mobility Lack of sensation

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FACTORS THAT INCREASE RISK FOR PANCREATITIS Gallstones Hyperlipidemia Hypercalcemia

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FACTORS THAT INCREASE RISK FOR PANCREATITIS Medications

Estrogen Furosemide ACE inhibitors Mesalamine

Alcohol abuse Cancer

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LEARNING OUTCOME 4Describe unique presentations of gastrointestinal

problems in the older person.

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PRESENTATION OF GI DISORDERS IN THE OLDER ADULT Present with different symptoms than the

younger adult Peptic ulcer disease

Impaired visceral pain perception Longer to recognize and report pain

Symptoms for gastric disorders tend to be vague

Symptoms may be attributed as a normal age-related change

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OTHER DISORDERS RESULTING IN GI SYSTEM CHANGES Diabetes Neurological illness Vascular disorders

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LEARNING OUTCOME 5Define appropriate nursing interventions directed

toward assisting the older adult with gastrointestinal problems to develop self-care

abilities.

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PATIENT EDUCATION NEEDS Presentation and reporting of symptoms of GI

problems in the older adult Impact of select medications on the GI

system Safe and appropriate use of prescribed

mediations Recommended health screenings for the GI

system

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LIFESTYLE MODIFICATION FOR GERD Lose weight as appropriate Avoid tight clothing Remain in upright position after eating Reduce alcohol, caffeine, and fat intake

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NURSING DIAGNOSES FOR PATIENTS WITH GERD Impaired swallowing Impaired skin integrity Impaired social interaction (if appropriate) Sleep pattern disturbance (if appropriate) Acute or chronic pain

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LIFESTYLE MODIFICATION FOR PEPTIC/DUODENAL ULCER DISEASE Discontinue use of all NSAIDs Discontinue use of alcohol, tobacco, and

caffeine Avoid offending foods

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LIFESTYLE MODIFICATIONS TO PREVENT DIVERTICULITIS AND MANAGE DIVERTICULAR DISEASE Increase dietary fiber Drink at least 8 full glasses of water per day

(unless contraindicated by other medical condition)

Do not ignore the urge to have a bowel movement

Exercise regularly Avoid foods that precipitate painful attacks

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EARLY DETECTION AND PREVENTION OF COLON CANCER Annual fecal occult blood testing Colonoscopy and sigmoidoscopy screenings

Initially begin with sigmoidoscopy Colonoscopy screening should begin at age 50

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NURSING MANAGEMENT OF CONSTIPATION Patient education

Dietary intake of fluid and fiber Exercise Awareness in bowel habits Understanding of potential impact of selected

medications

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LEARNING OUTCOME 6Identify and implement appropriate nursing

interventions to care for the older person with gastrointestinal problems.

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INTERVENTIONS TO PREVENT ASPIRATION Minimize distractions during eating Provide a pleasant mealtime environment Use consistent feeding techniques Document patient food preferences and

consumption patterns Position patient upright during and 1 hour

following mealtime Allow time for swallowing

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INTERVENTIONS TO PREVENT ASPIRATION Monitor respirations Provide oral hygiene before and after

mealtimes Provide meals when patient is rested Provide food and fluid of appropriate

consistencies

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INTERVENTIONS TO PREVENT ASPIRATION Never force-feed Monitor weight, function status, and patient

satisfaction during meals Evaluate swallowing capacity every 6 months

and prn Avoid nasogastric tubes

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NURSING DIAGNOSES FOR PATIENTS WITH DYSPHAGIA Impaired Swallowing Feeding Self-Care Deficit Risk for Fluid Volume Imbalance (Deficit) Ineffective Airway Clearance Risk for Aspiration Altered Dentition (if appropriate)

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RELATED FACTORS IDENTIFIED BY NANDA IN 2003 Neuromuscular impairment Decreased strength or excursion of muscles

involved in mastication Perceptual impairment

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RELATED FACTORS IDENTIFIED BY NANDA IN 2003 Mechanical obstruction (edema,

tracheostomy tube, tumor) Fatigue Limited awareness Reddened, irritated oropharyngeal cavity

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AGGRESSIVE NURSING INTERVENTIONS TO PREVENT DEHYDRATION Frequently assess pulse and blood pressure Establish schedule to offer fluids every 15 to

30 minutes Measure intake and output Assess skin turgor Notify primary care provider if dehydration is

imminent

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NURSING INTERVENTIONS FOR FECAL INCONTINENCE Regular toileting program Administration of high-fiber diet Elimination of medications associated with

diarrhea Treatment of infections

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ENDOSCOPIC GASTROINTESTINAL PROCEDURES Esophagogastroduodenoscopy

Restrict intake prior to procedure Strong laxative Antibiotics for patients at high risk for infection Oxygen during tube insertion

Sigmoidoscopy Sedation not required Phosphate enemas

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ENDOSCOPIC GASTROINTESTINAL PROCEDURES Colonoscopy

1 to 2 days of liquid diet Cathartic evening prior Monitor patients with cardiovascular or renal

instability

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NURSING DIAGNOSES ASSOCIATED WITH GASTROINTESTINAL TRACT PROBLEMS Imbalanced Nutrition: Less Than Body

Requirements for those with anorexia Risk for Infection, for those undergoing

endoscopic examination and needing antibiotic prophylaxis

Constipation and Perceived Constipation Diarrhea Bowel Incontinence

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NURSING DIAGNOSES ASSOCIATED WITH GASTROINTESTINAL TRACT PROBLEMS Risk for Constipation Ineffective Tissue perfusion: Gastrointestinal

Tract Risk for Aspiration Impaired Oral Mucous Membrane Social Isolation (if appropriate) Noncompliance (if appropriate)

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NURSING DIAGNOSES ASSOCIATED WITH GASTROINTESTINAL TRACT PROBLEMS Ineffective Breath Maintenance Toileting Self-Care Deficit Acute or Chronic Pain Disturbance Nausea

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