Care of Clients with Problems In Oxygenation, Fluids and Electrolytes, Metabolism and Endocrine (NCM103) Patients With Gastrointestinal

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Gastrointestinal Anatomy and Physiology

Terms:
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Digestion Occurs when enzymes mix with 4. General Signs and Symptoms ingested foods and when protein, fats and sugars are broken down into their component molecule Absorption Occurs when small molecules, vitamins and minerals pass through the walls of the small and large intestine and into the blood stream Elimination - Occurs after digestion and absorption when waste products are eliminated from the body

Topics Discussed Here Are: 1. Gastrointestinal Anatomy and Physiology a. Mouth b. Esophagus c. Stomach d. Small Intestine e. Large Intestine 2. Diagnostic Procedures 3. Assessment of the GIT System

Organs of the Digestive System

Anatomy and Physiology
Composed of 2 General Parts 1. Main GIT Starts from the mouth rectum 23 26 feet long (7 7.9 m) 2. The Accessory Organs Salivary glands Liver Pancreas Gall bladder Tongue Teeth

Blood Supply
The thoracic artery and abdominal aorta Portal venous system 5 large veins o Superior mesenteric o Inferior mesenteric o Gastric o Splenic and o Cystic veins Form the vena portal Liver Stomach Gastric Artery Intestines Mesenteric Artery

Nasal and Hormonal Regulation

Enteric Nervous System o If overstretched, it will be activated o Auerbachs Plexus (Motor Function) o Meissners Plexus (Sensory Function) Sympathetic Nervous System o Generally inhibits: Gastric secretions GIT motility Sphincter and blood vessels constrict Parasympathetic Nervous System o Generally excitatory: Gastric secretions GIT motility Sphincters relax VAGUS maVAGAL, The Enteric NS ACTS FIRST!

Anaphylactic Shock Histamine = POTENT VASODILATOR

CHANS
C Cardiogenic H Hypovolemia A Anaphylactic N Neurogenic S Septic Shock

Functions of the Digestive System

1. 2. 3. 4. 5. Take in food Breakdown the food Absorption, digests molecules Provide nutrients Elimination of wastes

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Factors that affect FooD Intake

1. 2. 3. 4. 5. 6. 7. Belief (religion, personal) Environmental Socio-cultural background Health status (Illness, disease state) Smell and taste Food presentation Mood/behavior

The Gastrointestinal Anatomy

Mouth
Speech, nutrient ingestion, initiation of mechanical and chemical digestion, swallowing Important for the mechanical digestion of food The saliva contains salivary amylase / Ptyalin then starts the initial digestion of carbohydrates

Important Structures of the Mouth 1. Teeth: Mechanical breakdown of food 2. Tongue: Tears and cut food into small pieces 3. Palate: Facilitates in swallowing : Articulation of words : It forms the roof of the mouth : Facilitates mastication / chewing 4. Salivary Glands: Produces serous / watery fluid Parotid Glands Produces PTYALIN for breakdown of starch Largest salivary gland Submandibular Gland Mixture of mucus and serous Produces serous and mucus Sublingual Gland Physiology of Mastication / Chewing Produces lubricating fluid, mucus Smallest salivary gland

Digesting Process
Chewing o 1.5 L of saliva is secreted daily from the parotid, submandibular and sublingual gland o Ptyalin / Salivary Amylase is an enzyme that begins the digestion of STARCH Swallowing o Begins as a VOLUNTARY act, which is regulated by the swallowing center in the medulla oblongata of the central nervous system (CNS)

The Esophagus
A hollow muscular tube Length: 25 cm (10 inches) Made up of stratified squamous epithelium Located in the mediastinum, anterior to the spine and posterior to the trachea and heart The Upper 3rd: Skeletal muscle, the upper esophagus / hypopharyngeal sphincter

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The Middle 3rd: Mixed skeletal and smooth muscle The Lower 3rd: Smooth muscle and the esophago-gastric / cardiac sphincter is formed here Functions to carry or propel foods from the oropharynx to the stomach Swallowing / Deglutition is composed of 3 phases: VPE 1. Orophyaryngeal Phase / Voluntary Phase 2. Pharyngeal Phase (Involuntary) 3. Esophageal Phase (Involuntary)

Lower esophageal sphincter relaxes just before another peristaltic wave

Longitudinal = PERISTALTIC MOVEMENT Circular = Churning / Mixing of CHYME

Stomach
It stores ingested food, secretes digestive juices and propels partially digests food (Chyme) into the duodenum J-shaped organ in the LUQ Contains several parts, the fundus, cardiac sphincter, body and pyloric sphincter The cardiac sphincter prevents the reflux of the contents into the esophagus (Entrance) The pyloric sphincter regulates the **** of gastric emptying into the duodenum (Exit) Capacity is 1,500 mL

Layers of the Digestive Tract Serosa Muscularis (Tunica Muscularis) Submucosa Mucosa

Outermost layer of the stomach, visceral peritoneum Produces the peristaltic activity of the stomach during digestion It contains the muscular and mucous layer of the stomach walls, and contains blood, lymph channels and nerve plexus

Gastric Function Stomach Secretes a high acidic fluid in response to the presence of ingested food Fluid can total as 2.4 L/day, can have a pH as low as 1 and derives its acidity from hydrochloric acid a. To breakdown food into more absorbable components b. To aid in the destruction of ingested bacteria Gastric Enzymes b. Secreted by Zymogenic cells / Chief Cells Amylase = For STARCH digestion Lipase = For FAT digestion Pepsin = For PROTEIN digestion Rennin = For MILK and PROTEIN digestion

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Secreted by Parietal Cells HCl = Main acid! 1.0 pH, destroys some bacteria ingested, aids also in digestion of food Intrinsic Factor = Aids in absorption of vitamin B12 *Pernicious Anemia* Secreted by Endocrine Cells Gastrin, Somatostatin, Serotonin Contraction of muscles

Types of Cells in the Stomach

1. 2. 3. 4. 5. 6. Mucus Neck Cells Surface Mucus Cells Parietal / Oxyntic cells Chief / Zygomonic Cell Endocrine Cell Regenerative HOW ARE GASTRIC JUICES SECRETED? WHERE DO THEY COME FROM? Gastric Secretion happens when there is: Presence of food in the mouth when chewing and swallowing Gastric distention Taste and smell of food Moderate amount of caffeine and alcohol Emotions such as anger and hostility They Came From: Mucous neck cells and surface mucus cells = Viscous and alkaline mucous that coats the surface epithelial cells of the stomach. It serves as a barrier that helps diffusion of hydrogen ions from gastric **** into mucosal cell If barrier is damaged ULCER is formed Parietal Cells: It produces HCl and Intrinsic Factors (IF) Endocrine Cells: Gastrin which stimulates pancreatic cells to increase secretion Gastrin Production is INCREASED by: a. Gastric Distention b. Vagal stimulation c. Calcium Ions d. Presence of protein breakdown products Gastrin production is Inhibited by a gastric pH LESS than 1.5 HOW IS HCl ACID FORMED??

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Phases of Gastric Secretions

Cephalic Phase Is dependent on stimulation of gastric secretion by receptors in the brain that are mediated by the vagus nerve Gastric Phase Secretion occurs when the bolus of food reaches the antrum. This phase consists of 3 mechanisms: 1. When food enters the stomach 2. Secretion of gastric juice 3. Continuity of phase until acidity of the gastric contents reaches a pH of 1.5 Distention of stomach > Carried action potential to medulla oblongata > stimulate stomach secretion, distend of stomach activate local reflex to increase HCl, pepsinogen and gastrin by the stomach mucosa Intestinal Phase Primarily inhibits gastric secretion in 3 ways 1. Sensory Vagal Inhibit motor action, potential from medulla 2. Local Reflex Inhibit secretion of the stomach mucosa 3. Secretin, gastric inhibitory polypeptide and cholecystokinin Inhibit secretion of stomach mucosa Stimulate with passage of food into the duodenum resulting to secretion of small amount of gastrin by intestine
Pathophysiology of Deglutition and Digestion Swallowing causes the fundus to relax to receive a bolus

Anticipatory and prepare stomach to receive food, tactile sensation stimulate the medulla oblongata > action carried to vagus > stomach stimulate to secrete HCl, pepsinogen, IF, gastrin > gastrin stimulate parietal cell secrete HCl and chief cell secrete pepsinogen

Mixing occurs as food is propelled toward the antrum Food apply the pylorus

Velocity of peristaltic wave

Movement in the Stomach Mixing Wave o Weak contraction of muscle causing thoroughly mixed ingestion o Food with stomach secretions o Primarily act to combine ingested nutrients with gastric secretion Peristaltic Wave o Stronger contraction which force the chime towards the pylorus *** Ingested nutrients remain in the stomach until they have been thoroughly mixed with gastric content and converted to semi-fluid material called CHYME

The passage of the contractile wave over the gastric content forces the chyme back towards the body of the stomach Retropulsion

Food effectively mixes with digestive juices and oscillate

Small Intestine
Circular and longitudinal layer Function: Duodenal secretion concentrate from the accessory digestive organs pancreas, liver and gall bladder and glands on the intestinal walls (Pancreatic secretions have an alkaline pH) Has 3 Parts: Duodenum

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30 30 cm Connects CBD and Pancreatic duct both empty at the Duodenum at the Ampulla of Vater to pyloric sphincter Jejunum 2/3 Major organ for absorption of nutrients Has very prominent villi, consistent with its role in nutrient absorption Ileum 3/5 Peyers Patches, cluster of lymph nodes that are numerous in the ileum LONGEST PART! 12 feet For absorption of nutrient not absorbed in the duodenum and jejunum Villi are less prominent Site for absorption of IF, Vit B12, and bile salts, found in the terminal ileum

4 Types of Cells in the Mucosa of the Small Intestine

Absorptive: Produce digestive enzymes and absorb digestive food Goblet Cells: Produces protective mass Endocrine: Produce regulatory hormones

Secretions of Small Intestine:

Secretion of mucosa consists of mucous, ion and water which lubricate and protect the intestinal wall from acidic chime and enzyme Most secretions of that enter small intestine comes from the intestinal mucosa while secretion of liver and pancreas play a role in digestion Epithelial cells of small intestine relapsed enzyme that pay a role in final stage of digestion Produce digestive enzyme and absorb digestive food. Peptidase forms peptide bonds to form amino acid CCK to release bile to duodenum Secretions contribute to decrease acidity Acidity from the stomach should not maintain in duodenum At least pH of 3 and above to make the pancreatic enzymes work effectively During digestion: CHO Monosaccharides CHON Amino Acids Fats Monoglycerides / Glycerides

Two Types of Contractions in the Small Intestine

a. Segmental Contractions Mixing waves that move the intestinal contents back and fourth in a churning motion Also with contraction and relaxation which propagate for only a short distance and function b. Peristaltic Contraction (Intestinal Peristalsis?) Propels the content toward the colon *** Both movements are stimulated by the presence of CHYME! *** Fingerlike projection/ villi are present throughout the SI

Large Intestine
Circular and longitudinal layers Functions: Absorption of water and salt, bacteria inhabit the colon, synthesize Vit K which is absorbed in the colon

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Different Parts: Cecum: Proximal end of large intestine, located in RLQ of abdomen (Loudest part for auscultation of bowel sounds) Connects ileum to colon, which contain the ileococal valve A one way valve that prevents reflux of large bowel content into the SI Organ responsible for storing and eliminating waste products produced by nutrient digestion and absorption Appendix Tube that is about 6 cm past ileococal junction, attached to the cecum Colon Ascending, transverse, descending, sigmoid Rectum Straight muscular, signals defecation IF Stretched! It will DEFECATE Opens internal sphincter to defecate (involuntary) and external anal sphincter (voluntary) Transit Time = Watery stool / diarrhea Transit Time = HARD STOOL!

Defecation Reflex Mass Movement (Occurs 8 12 hours) Colonic Motility: Propulsive movement of the colon occur as mass movement which is a series of peristaltic waves that sweep stool rapidly through the colon Peristaltic movement = 10 15 minutes 2 3 times per day, common in the 1st hour after breakfast Feces Component Undigested food stuff, inorganic matter, undigestive roughage, epithelial cells, components of digestive juices Gases Methane, Hydrogen sulfide * ammonia Elimination begins with distention of the rectum which initate contraction of the rectal musculature Stool is normally brown in color, due to the derivatives of bilirubin FLATUS ACTION of colonic bacteria on undigested food

DIAGNOSTIC PROCEDURES
PAPER! Provides information about the procedure Alleviate anxiety, help client cope with the discomfort Provide instruction about post procedure care and activities Encourage family members to offer emotional support Reassess and assess patient for adequate hydration before, during and after the procedure GIT Study: X-Ray Scope Direct visualization Laparoscopy Fiber, optic tube Endoscopy and Fibernoscopy Get consent 24 hours prior to procedure On NPO (at least 8 hours before procedure) Left SIMS position to prevent aspiration Light sedation Upper GI series / Barium swallow Lower GI series / Barium Enema

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PostOp!: Monitor gag reflex, bleeding, reflex bradycardia, pulse Andoscopy and Sigmoidoscopy CT Scan: Visualize to see a tumor, organ enlargement MRI: Exact Metastatic structure Remove METAL APPLIANCE! Assess allergy to dye (Iodine) Contraindicated with renal failure OFI Ultrasonography Lab Studies Fecalysis: Integrity of GI tract, yellow in color Stool Culture Bacteriostatic study, specific bacteria, bacteria will manifest in stool They will get every morning for 3 consecutive days via cotton applicator to anus then rotate cotton applicator then place on sterile bottle Gastric Analysis Occult Blood Test: Normal blood in stool: 25 mL or less/day

ASSESSMENT of The GASTROINTESTINAL SYSTEM

Complete History Demographic Data Psychosocial History Family History Medication, diet and nutrition Socio-economic status History of Present Illness (HPI) Changes in bowel movement Color and consistency of stool Occurrence of diarrhea Weight gain / loss Blood in stool or vomitus Abdominal Pain??? OBJECTIVE Inspection Mouth, tongue, Buccal mucosa, gums Dentures should be removed Check for contour, symmetry of abdomen (globular, convex-spoon, concavebig) Skin changes and scars from previous operations, lesions, division of hairs (unequal/equal distribution) Inspect for bulging, distention and visible peristaltic wave (Ascites) Anal and perineal area 1. Inspect for areas of excoriation 2. Fissures 3. Fistula 4. External hemorrhoid Auscultation Character and location of frequency of bowel sounds Bowel sounds are assessed in 4 quadrants using the DIAPHRAGM of the stethoscope (Borborygmi) ?? Use the bell of the stethoscope on the Aorta, there should be no bruit (sabi ni sir)

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Normal Hypoactive Hyperactive Absent

Finding Every 5 20 seconds 1 2 in 2 minutes 5 6 in less than 30 seconds 0 in 3 5 minutes

Percussion Has limited values of physical assessment, it may be difficult to perform if patients are obese. Findings may vary due to different proportions TYMPANY will be appreciated on hollow organs (Stomach) DULLNESS will be over solid organs (Liver and suspected masses) Instruct the client to VOID prior to PHYSICAL ASSESSMENT of the abdomen Palpation Light Palpation: 1. Used to identify areas of tenderness or swelling (at least inch or 2 3 cm) 2. In light palpation, note any palpable mass Deep Palpation: 1. Used to identify masses in any of the quadrants (at least 2 inches) 2. In deep palpation, detail examination of the mass found in the light palpation All four quadrants Light, then DEEP

General Signs and Symptoms

Anorexia Is a lack of desire to eat despite physiologic stimuli that would normally produce hunger Is anon specific symptom that is often associated with: 1. Nausea 2. Abdominal pain 3. Diarrhea Disorders of other systems accompanied by anorexia: Cancer Heart disease Renal disease Treatment: Ice chips Tea or crackers Small frequent feedings Vomiting Forceful emptying of stomach and intestinal contents (Chyme) through the mouth Nausea Act of feeling want to vomit Constipation Diarrhea Abdominal Pain

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Constipation Abnormal multiple Pathophysiology - Interference with the 3 functions of the COLON 1. Mucosal transport 2. Myoelectric activity 3. Process of defecation Nursing Intervention Assist physically in treating the underlying cause of constipation Diarrhea Frequency of bowel movement More than 3 times a day amount of stool Altered consistency Abnormal fluid of the stool Multiple causes Gastrointestinal Disease Hyperthyroidism Food Poisoning Nursing Intervention: Fluid intake Determine and manage case Antidiarrheal drugs Prescribed symptoms of a number GIT diseases Causes: Mechanical Inflammation Ischemic Abdominal Pain Kinds of Abdominal Pain Parietal Pain Visceral Pain Associated Pain Referred pain

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