The Aging GI System

• Nutrition– Good nutrition is essential in seniors

• Age related changes– Decreased saliva production– Decreased gag response– Altered intestinal enzymes– Abdominal wall/muscles get weaker– Decreased intestinal tone– Decreased peristalsis

Medications often affect the taste of food and can contribute

to altered nutrition.

The Aging Mouth and Teeth

• Teeth may be loose or broken

• Dentures may not be with patient, may not fit well

• Gums may be swollen r/t misfit dentures

• Halitosis!

• Chewing & Swallowing difficulties

Oral Hygiene

• Losing teeth with age is no longer a ‘normal’ process

• Stress, emphasize and perform meticulous frequent oral hygiene

• Missing/loose teeth make chewing painful

• Let your supervisors know that Medicare will reimburse for fluoride application in seniors.

Weight Changes

• 75-90 year olds need only 14kCal/lb vs. 20-37 year olds needing 18kCal/lb/day

• With the decreased caloric intake, the need to eat nutrient rich foods increases!

Kcal needs/day

150 pound person

20-37 year old 2700 kCal

75-90 year old 2100 kCal

Aging Bowels

• Assess BM for frequency, amount, odor, consistency, & color

• What is normal for the individual?

• Laxative use?

• Assess abdomen for tenderness, distention & Bowel Sounds– Bowel sounds need to be assessed on all

clients!

• Annual fecal occult blood testing is recommended for all adults over 50.

Intake

• Need a minimum of 1500ml/day of fluid

• Seniors may decrease intake to avoid incontinence

• Bladder training (go q2h)

• Assess for dehydration

Laboratory and Diagnostic Examinations

• Upper GI series

• Gastric analysis

• Esophagogastroduodenoscopy (EGD)

• Barium swallow

• Bernstein test

• Stool for occult blood

• Barium enema• Colonoscopy• Sigmoidoscopy• Stool culture and sensitivity• Stool for ova and parasites• Flat plate of the abdomen

LAB. AND DIAGNOSTIC EXAMS

• UPPER GI SERIES:

1. This consists of a series of radiographs of the lower esophagus, stomach, and duodenum. Barium sulfate is used as the contrast medium.

2. An UGI series will detect any abnormal conditions of the upper GI tract, any tumors, or other lesions.

Laboratory Tests

• Blood Ammonia

• Hepatitis Virus Studies

• Serum Amylase Test

• Urine amylase Test

• Stool Culture & Sensitivity

• Serum bilirubin test

• Liver enzyme test

• Serum protein test

• Stool for Ova & Parasites

• Stool for Occult Blood

Serum Bilirubin Test

• Direct Bilirubin = 0.1 - 0.3 mg/dl

• Indirect Bilirubin = 0.2 - 0.8 mg/dl

• Total Bilirubin = 0.3 – 1 mg/dl

• Total Bilirubin in Newborns = 1 – 12 mg/dl

• Jaundice is present at 2.5 mg/dl total serum bilirubin

Bhutani Nomogram

UGI SERIES

UGI SERIES, cont.

• NURSING INTERVENTIONS: 1. NPO after midnight. 2. No smoking after midnight. 3. Explain the importance of rectally expelling

all the barium after the exam. Stools will be light-colored until all of the barium has been expelled up to 72 hours after the test.

4. Absorption of fecal water may cause a hardened barium impaction.

5. Encourage the increase of water intake. 6. MOM may be given.

TUBE GASTRIC ANALYSIS

• 1. The contents of the stomach are aspirated to determine the amount of acid produced by the parietal cells in the stomach.

• 2. The analysis is done to determine the completeness of a vagotomy; confirm hyersecretion or achlorhydria (an abnormal condition characterized by the absence of HCl acid in the gastric juice); estimate acid secretory capacity; or assay for the intrinsic factor.

GASTRIC ANALYSIS, cont.

• NURSING INTERVENTIONS:

1. No anticholinergic drugs for 24 hours before the test.

2. NPO after MN. 3. No smoking before the

test. (this stimulates the flow of gastric secretions.

4. An NG tube will be inserted for the test, then removed.

5. The pt. may if indicated.

ESOPHAGOGASTODUODENOSCOPY(EGD, UGI Endoscopy, Gastrostomy)

• 1. This test enables direct visualization of the upper GI tract by means of a long, fiberoptic, flexible tube.

• 2. The esophagus, stomach, and duodenum are examined for tumors, varices, mucosal inflammation, hiatal hernias, polyps, ulcers, the presence of H. Pylori, strictures, and obstructions.

• 3. The endoscopist can remove polyps, coagulate sources of bleeding, and perform sclerotherapy of esophageal varices through endoscopy.

• 4. Areas of stricture can be dilated by the passing of a dilator through the scope, or by the endoscope itself.

• 5. A camera can be attached; photos can be taken of the pathology.

• 6. Tissues specimens can be obtained for bx. or culture to determine the presence of H.Pylori.

GASTROSCOPY

NURSING INTERVENTIONS

• 1. Explain the procedure to the pt.• 2. NPO after MN.• 3. The pt. must sign a consent form and complete a pre-

operative checklist for the exam.• 4. The pt. is usually given a pre-procedure IV sedative,

such as Versed.• 5. The pt.’s pharynx has been anesthetized by a

Lidocaine spray. Because of this, the nurse must not allow the pt. to eat or drink until the gag reflex returns. (usually about 2-4 hours)

• 6. Assess for s/s of perforation, including abdominal pain, guarding, melena, oral bleeding, hypovolemic shock.

GASTROGRAFIN STUDIES

BARIUM SWALLOW (GASTROGRAFIN STUDIES)

• 1. This study is a more thorough study of the esophagus than what is provided by most UGI exams.

• 2. It will show defects in luminal filling and narrowing of the barium column: these indicate tumors, scarred stricture, esophageal varices.

• 3. Anatomical abnormalities are easily seen, such as a hiatal hernia.

• 4. Left atrial dilation, aortic aneurysms, mediastinal tumors may cause extrinsic compression pf the barium column within the esophagus.

BARIUIM SWALLOW, cont.

• 5. A product called Gastrografin is now used instead of Barium for pts. in whom bleeding from the GI system may occur and surgery is being considered. Gastrografin is water-soluble and rapidly absorbed, so it is preferable when a perforation is suspected.

BARIUM or GASTROGRAFIN SWALLOWS

ESOPHAGEAL FUNCTION STUDIES (Bernstein Test)

• 1. The Bernstein test is an acid-perfusion test.• 2. It is an attempt to reproduce the sx. of

gastrophageal reflux. • 3. It aids in differentiating esophageal pain

caused by esophageal reflux from that caused by angina pectoris. If the pt. suffers from pain with the instillation of HCl acid into the esophagus, the test is positive and indicates reflux esophagitis.

NURSING INTERVENTIONS

• 1. The nurse should avoid sedating the pt., because the pt.’s participation is essential for swallowing the tubes, swallowing during acid clearance, and describing any discomfort during the instillation of HCl acid.

• 2. The pt. is NPO for 8 hours before the exam.• 3. Any meds. that may interfered with the

production of acid, such as antacids and analgesics, are withheld.

EXAMINATION OF STOOL FOR OCCULT BLOOD

• 1. Tumors of the large intestine grow into the lumen and are subjected to repeated trauma by the fecal stream.

• 2. Eventually, the tumor ulcerates and bleeding occurs. Usually the bleeding is so slight that blood is not seen in the stool.

• 3. If occult blood (blood that is obscure) is detected in the stool, then a GI tumor should be suspected.

• 4. Tests for occult blood are called guaiac, Hemoccult, and Hematest.

GUAIAC STOOLS

• 4. Occult blood may occur in ulceration and inflammation of the upper or lower GI system.

• 5. Other causes include swallowing blood of oral or nasopharyngeal origin.

• 6. Stool is obtained by digital retrieval. It is placed in an appropriate container (plastic cup with a cover). It must be obtained before barium studies are done.

HEMOCCULT TEST

NURSING INTERVENTIONS• 1. Instruct the pt. to keep the stool

specimen free of urine or TP, because either one can contaminate the specimen and alter the test results.

• 2. The nurse should don gloves, use a tongue blade to transfer the stool to the cup or container.

• 3. Keep the pt.’s diet free of red meat for 24-48 hours BEFORE a guaiac test.

SIGMOIDOSCOPY

• 1. An endoscopy of the lower GI tract.

• 2. Can obtain bx. of tumors, polyps, or ulcerations of the anus, rectum, and sigmoid colon.

• 3. Allows direct visualization. Can provide the dx. for many lower bowel disorders

NURSING INTERVENTIONS

• 1. Explain the procedure to the pt.• 2. The pt. must sign a consent form.• 3. The pt. receives enemas as ordered on

the evening before the procedure, OR on the morning of the exam.

• 4. The nurse observes the pt. for evidence pf bowel perforation: abdominal pain or tenderness, distention, and bleeding.

BARIUM ENEMA STUDY (lower GI series)

• The barium enema (BE) study consists of a series of radiographs of the colon used to demonstrate the presence and location of polyps, tumors, and diverticula.

• Positional abnormalities can also be seen. (such as malrotation)

• Barium sulfate is more effective for visualizing mucosal detail.

• The BE study may be used to reduce nonstrangulated ileocolic intussusception in children. Intussusception is the infolding of one segment of the intestine into the lumen of another segment.

THE BARIUM ENEMA

NURSING INTERVENTIONS when a BE study is ordered.

• 1. Administer cathartics, such as magnesium citrate (or what is ordered) the night before the test.

• 2. A cleansing enema may be given the night before or the morning of the procedure.

• 3. MOM may be ordered after the BE to stimulate the evacuation pf the barium.

• 4. Assess the pt. for complete evacuation of the barium. Retained barium may cause a hardened impaction. Stool will be light-colored until the barium has been expelled.

COLONOSCOPY

– A new fiberoptic endoscope has been developed. With this new scope, a higher percentage of pts. can have the entire colon (from anus to cecum) examined.

– Benign and malignant neoplasms, mucosal inflammation or ulceration, and sites pf active hemorrhage can be visualized.

– Bx. specimens can be obtained.– Small tumors can be removed through the

scope.– Actively bleeding vessels can be coagulated.

COLONOSCOPY

COLONOSCOPY, cont.

• Pts. who have had colon cancer , or pts. who have a family hx. of colon cancer are at increased risk for getting colon cancer.

• For these pts., a colonoscopy allows early detection of any primary or secondary tumors.

NURSING INTERVENTIONS for pts. getting a colonoscopy exam

• 1. The pt. signs a consent form.• 2. The pt. receives diet instructions: • a. Usually a clear liquid diet is permitted 1-3

days before the procedure.• b. NPO for 8 hours before the procedure.• 3. The nurse administers a cathartic, enemas,

and premedication as ordered to decrease the residue in the bowel. GoLYTELY is commonly used. It is an osmotic electrolyte solution.

Go-LYTELY

• 4. Give orally or by NG tube. • 5. Give fast. 8 ounces every 15 min. until

enough solution has been consumed to make the colonic contents a light yellow liquid. Taking the solution slowly will not clean the colon efficiently.

• 6. You may add powdered lemonade so it is more palatable.

• 7. Provide warm blankets during the procedure. Many pts. experience hypothermia during the Go-LYTELY procedure.

• 8. Provide a commode at the bedside.• 9. A pre-procedure IV sedative (Versed) is

usually given.• 10. After the procedure, the nurse checks for

evidence of bowel perforation (abdominal pain or tenderness, guarding, distention, excessive rectal bleeding, or blood clots).

• 11. The nurse examines the stool for gross blood (and tells the pt. to notify them if s/he has any of these s/sx).

• 12. Assess for hypovolemic shock.

BOWEL PERFORATION

STOOL CULTURE

• The feces can be examined for the presence of bacteria, ova, and parasites.

• Many bacteria are indigenous to the bowel. (E. Coli)

• Bacterial cultures are usually done to detect enteropathogens (such as Staphylococcus aureus, Shigella, Salmonella, etc.)

STOOL CULTURE, cont.

• When a pt. is suspected of having a parasite, the stool is examined for O & P. Three specimens are collected on subsequent days.

• The cultures will not be back for several days. The initial treatment will be the same until the culture results come back.

STOOL CULTURE

NURSING INTERVENTIONS(stool culture)

• 1. If an enema is ordered, only NS or tap water should be used.

• 2. Soapsuds or any other substance could affect the viability of the organisms collected.

• 3. Stool samples for O & P are collected BEFORE the barium exam.

• 4. The pt. should not mix urine with feces.• 5. The specimen should be taken to the lab

within 30 minutes of collection in a specified container.

OBSTRUCTION SERIES (FLAT PLATE OF THE ABDOMEN)• This series is a group of radiographic

studies performed on the abdomen of a pt. who has a suspected bowel viscus perforation, obstruction, paralytic ileus, or abdominal abscess.

• This series usually consists of two radiographic studies. The first is an erect abdominal radiographic study that should include visualization of the diaphragm.

OBSTRUCTION SERIES, cont.

• Radiographs are examined for evidence of free air under the diaphragm, which is pathognomonic (s/s specific to a disease condition) of a perforated viscus.

• This study also is used to detect air-fluid levels within the intestine.

NURSING INTERVENTION: Ensure that this study is scheduled BEFORE any barium studies.

FLAT PLATE OF THE ABDOMEN

Oral Cholecystography (OCG)• X-Rays of the gallbladder after ingestion of

dye tables the night before• Less accurate than a gallbladder U/S.

Nursing – • Ensure client not allergic to iodine• 6 tablets given q 5min, after evening meal• NPO after MN• May be on high fat diet to stimulate

gallbladder

Intravenous Cholangiography (IVC)

• IV dye concentrated in liver & secreted into common bile duct

• Allows visualization of the hepatic and common bile ducts and the gallbladder if cystic duct is present

• Less commonly used method

Operative Cholangiography

• The common bile duct is directly injected with radiopaque dye.

• Stones appear as radiolucent shadows

• Tumors cause partial or complete obstruction of the flow of dye to the duodenum

• Gives the surgeon a ‘road map’ of the biliary duct structures

T-Tube Cholangiography

• aka ‘post operative cholangiography’

• Performed to dx retained ductal stones postop in clients with a cholecystectomy and common duct exploration (CDE)

• T-shaped rubber tube place by surgeon in the bile duct during the operation.

• Through the end of the T-tube, dye can be injected and X-Rays taken

T-Tube Cholangiography (con’t)

• Nursing Interventions– Protect client from sepsis, connect tube to a

sterile closed drainage system– Check for iodine allergy prior to dye

placement (before surgery??)– NPO after MN– Administer a lovely and refreshing morning

cleansing enema.

U/S of the Liver, Gallbladder & Biliary System

• NPO after MN (with advanced notice)

• If client has had barium contrast studies done recently, get an order for a cathartic.

• U/S does not penetrate barium

Other Tests

• Gallbladder Scanning (Hepatobiliary Scintigraphy Imaging, HIDA Scanning)

• Needle Liver Biopsy• Radioisotope Liver Scanning

– After IV administration of radioactive dye, a Geiger counter is passed over the patient’s abdomen to record radioactivity in the liver

• U/S of pancreas• CT of the abdomen

Endoscopic Retrograde Cholangiopancreatography (ERCP)

ERCP Nursing Interventions

• NPO for 8 hrs. prior to procedure

• Ensure informed consent

• Teach client that the test takes about 1-2 hours, and that they must remain motionless on a hard x-ray table which may be uncomfortable.

• Keep client NPO after procedure until gag reflex returns (2-4 hours)

GI Assessment

• LOC• V/S • Skin Color• Edema• Appetite • Weight Loss• N/V• Bowel Habits

– Frequency, color, odor amount & consistency

• Assess abdomen for distention, guarding & peristalsis

• Obtain past hx of smoking, ETOH use, medication

• Pain level & location• Stressors• Coping level• Anticipate dx procedures