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 constipation-predominant 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• Diarrhea—pus 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• Crohn’s 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

• Crohn’s 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

Crohn’s 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 ProcessNursing 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, LET’S GO HOME!!

Nursing Diagnoses