361 GI Reading Notes Accessory Digestive Organs Liver and gallbladder Liver is encased in a fibroelastic capsule (Glisson capsule) that contains blood vessels, lymphatics, and nerves When liver is diseased or swollen, distention causes pain and the lymphatics may ooze fluid into peritoneal cavity Liver tissue consists of lobules composed of plates of hepatocytes (liver cells) Sinusoids, blood-filled spaces within the lobules, are lined with Kupffer cells (phagocytic, remove debris from the blood) Bile production is liver?s primary digestive function Greenish, watery solution containing bile salts, cholesterol, bilirubin, electrolytes, water, and phospholipids When bile is not needed for digestion, sphincter of Oddi (where bile enters duodenum) is closed and bile backs up the cystic duct into gallbladder for storage Cystic duct joins hepatic duct to form common bile duct, from which bile enters into duodenum Exocrine pancreas Located between stomach and small intestine Primary enzyme-producing organ of digestive system Through secretory units called acini, secretes alkaline pancreatic juice containing many different enzymes Pancreas produces from 1-1.5L of pancreatic juice/day Alkaline fluid neutralizes acidic chime as it enters duodenum, optimizing pH for intestinal and pancreatic enzyme activity Client with obesity Excess of adipose tissue More accurately defined by BMI, indirect measure of amount of body fat BMI 25+ is overweight BMI 30+ is obese Risk factors: heredity, physical inactivity, cultural and environmental factors (increased time spent watching tv), sociocultural influences, socioeconomic status, psychological factors Patho: when excess calories are stored as fat, can result from excess energy intake, decreased energy expenditure, or combination of both Hunger center in hypothalamus stimulates appetite in response to stimuli As nutrient levels rise, satiety center sends the message to stop eating GI filling and hormonal factors also signal satiety (sensation of fullness) Hormones involved: thyroid hormone, insulin, leptin Upper body obesity: central obesity, defined by waist-to-hip ratio of greater than 1 in men and .8 in women Associated with greater risk of complications like hypertension, abnormal blood lipid levels, heart disease, stroke, and elevated insulin levels Lower body obesity: peripheral, waist to hip ratio is less than 0.8, more common in women Complications: Morbid obesity: increase risk of dying x12 CV disease, hypertension, CHD, heart failure, stroke, atherosclerosis, metabolic syndrome, obesity-associated obstructive sleep apnea Risk of insulin resistance, risk for gallstones, risk for cancer (colon, breast, and endometrial), joint pain and arthritis Behavior modification: critical component, strategies like keeping food records, eliminating cues that precipitate eating, changing act of eating Sx: bariatric surgery NURSING DIAGNOSES Imbalanced nutrition: more than body requirements (imbalance of kcal consumption to energy expenditure) Activity intolerance (clients may experience excess fatigue, tachycardia, and shortness of breath with activity due to physiologic effects of excess weight as well as sedentary lifestyle Ineffective Therapeutic Regimen management (integrating all components of a weight loss program into a daily routine Chronic Low self-esteem Client with Malnutrition Inadequate intake of nutrients due to lack of major nutrients (calories, carbs, proteins, fats) or micronutrients (vitamins, minerals) Groups at risk in US: young, poor, elderly, homeless, low-income women, ethnic minorities Risk factors: age, poverty/homelessness, functional health problems that limit mobility or vision, hx of weight loss of more than 20% usual weight, oral or gi problems that affect food intake/digestion/absorption, inability to eat for 5+ days, chronic pain or chronic diseases, dementia, mental health disorders, meds or treatments that affect appetite, alcohol or drug addiction, acute problems like infection/surgery/trauma Starvation: glycogen is used to provide energy, formation of glucose from proteins for energy, break down fats into free fatty acids and ketones for energy Size of all body compartments is reduced a sbody fats and muscle proteins are used to meet energy needs As lean body mass is reduced, metabolically active tissue is lost, and energy expenditure decreases Acute stress response- state of hypermetabolism and catabolism (cell and tissue breakdown), increases energy expenditure and nutrient needs Protein-calorie malnutrition Manifestations: wasted appearance, dry and brittle hair, pale mucous membranes, peripheral or abdominal edema Enteral nutrition: tube feeding, may be used to meet calorie and protein requirements in clients unable to consume adequate food Indications: difficulty swallowing, unresponsiveness, oral or neck surgery or trauma, anorexia, serious illness Complications: aspiration, diarrhea Parenteral nutrition: IV admin of carbs, protein, electrolytes, vitamins, minerals, and fat emulsions (hypertonic solutions) NURSING DIAGNOSES Imbalanced nutrition: less than body requirements Risk for infection (malnutrition affects many components of the immune system, including the skin, mucous membranes, and lymph tissue and cells) Risk for deficient fluid volume (difficulty swallowing food an fluids or admin of hyperosmolar nutritional solutions may lead to dehydration or electrolyte disturbances Client with eating disorder Anorexia nervosa: body weight less than 85% of expected for age and height and intense fear of gaining weight or of loss of control over food intake Bulimia nervosa: recurring episodes of binge eating followed by purge behaviors such as excessive exercise Bing-eating disorder: recurrent episodes of binge eating- eating an excessive amount of food during a defined period of time and a sense of lack of control over eating during binge episodes NURSING DIAGNOSES Imbalanced nutrition: less than body requirements Imbalanced nutrition: more than body requirements Ineffective sexuality patterns Chronic low self-esteem Disturbed body image Ineffective therapeutic regimen management: family Powerlessness Client with stomatitis Inflammation of oral mucosa May be caused by viral or fungal infections, mechanical trauma, irritants like tobacco or chemotherapeutic agents Risk factors: 65+ years old, impaired immune status, chronic renal failure or CHF, chemotherapy/radiation therapy, oxygen therapy/mouth breathing, meds, poor oral hygiene, tobacco or alcohol use Chemotherapy or chemical irritation may result in initial generalized redness and swelling, followed by development of deep, irregular ulcerations Ulcers may be covered with pseudomembranes Oral pain an pseudomembranes can interfere with ability to eat, drink, and swallow normally Stomatitis can lead to malnutrition, fluid and electrolyte imbalance, and other complications such as sepsis and bacterial endocarditis NURSING DIAGNOSES Impaired oral mucous membrane Imbalanced nutrition: less than body requirements (oral lesions and pain may limit oral intake) Client with Gastroesophageal reflux disease Backward flow of gastric contents into esophagus May result from transient relaxation of lower esophageal sphincter, an incompetent lower esophageal sphincter, and/or increased pressure within the stomach Manifestations: heartburn, usually after meals, with bending over or when reclining, regurgitation of sour material into the mouth, or difficulty and pain with swallowing may develop Complications: esophageal strictures, Barrett?s esophagus (characterized by changes in cells lining the esophagus and increased risk of developing esophageal cancer); strictures can lead to dysphagia Nutrition and lifestyle management: acidic foods (tomato, citrus fruits, spicy foods, coffee, etc) are eliminated from diet; fatty foods , choc, peppermint, and alcohol relax lower esophageal sphincter or delay gastric emptying, so they should be avoided NURSING DIAGNOSES Pain Client with hiatal hernia Occurs when part of the stomach protrudes through the esophageal hiatus of the diaphragm into the thoracic cavity Often asymptomatic Sliding hiatal hernia: gastroesophageal junction and fundus of the stomach slide upward through the esophageal hiatus Paraesophageal hiatal hernia: junction between esophagus and stomach remains in its normal position below the diaphragm while a part of the stomach herniates thru the esophageal hiatus May develop gastritis or chronic or acute gi bleeding Barium swallow or upper endoscopy may be done to diagnose hiatal hernia Manifestations: reflux, heartburn, feeling of fullness, substernal chest pain, dysphagia, occult bleeding, belching, indigestion Client with impaired esophageal motility Disorders can cause dysphagia (difficult or painful swallowing) or chest pain Achalasia: characterized by impaired peristalsis of smooth muscle of esophagus and impaired relaxation of lower esophageal sphincter Fullness in chest during meals, chest pain, nighttime cough, dysphagia Diffuse esophageal spasm: nonperistaltic contraction of esophageal smooth muscle Chest pain, dysphagia Overview of normal physiology: stomach and duodenum Gastric mucosal barrier includes: An impermeable hydrophobic lipid layer that covers gastric epithelial cells Bicarbonate ions secreted in response to hydrochloric acid secretion by the parietal cell sof the stomach Mucous gel that protects the surface of the stomach lining from the damaging effects of pepsin and traps bicarbonate to neutralize hydrochloric acid When disease alters processes that maintain barrier, gastric mucosa becomes irritated and inflamed Bile acids also break down the lipids in the mucosal barrier, increasing potential for irritation Aspirin and NSAIDs also alter nature of gastric mucus, affecting its protective function Client with nausea and vomiting Nausea: vague, but unpleasant sensation of sickness or queasiness Vomiting: forceful expulsion of the contents of the upper gastrointestinal tract resulting from contraction of muscles in the gut and abdominal wall Vomiting center can be stimulated by: Gi tract produced by distention, irritation, or infection Vestibular system of ear Higher CNS centers in response to certain sights, smells, or emotional experiences Chemoreceptors outside blood-brain barrier that are stimulated by drugs, chemotherapeutic agents, toxins, systemic disorders, pregnancy Disorders like acute myocardial infarction and heart failure commonly produce nausea and vomiting Increased ICP Vomiting, which stimulates the vagus nerve and parasympathetic nervous system, may be accompanied by dizziness, light-headedness, hypotension, and bradycardia Potential complications: dehydration, hypokalemia, metabolic alkalosis, aspiration with resulting pneumonia, rupture or tears of the esophagus NURSING DIAGNOSES Nausea (nursing dx defined as subjective, unpleasant, wavelike sensation in the throat, epigastric region, or abdomen that may lead to vomiting Client with GI bleeding Three primary disorders leading to upper GI hemorrhage: erosive gastritis, peptic ulcer disease, esophageal varices Hematemesis: vomiting blood Partially digested blood may have coffee-ground appearance Melena: black and tarry stools Hematochezia: frankly bloody stools Occult bleeding: hidden, detected by chemical means Manifestations of decreased cardiac output (tachycardia, hypotension, pallor, decreased urine output), hypovolemic shock progresses, leading to acidosis, renal failure, bowel infarction, acute coronary syndrome, coma, and death Gastric lavage: washing out of stomach contents, to remove blood from GI tract, prevent vomiting, and prepare for upper endoscopy NURSING DIAGNOSES Decreased cardiac output (as blood volume drops, venous return decreases, hr increases to maintain cardiac output, and peripheral blood vessels constrict to improve venous return and cardiac output Impaired tissue integrity: gastrointestinal Client with gastritis Inflammation of the stomach lining, results from irritation of the gastric mucosa Acute gastritis: disruption of mucosal barrier by local irritant Irritation, inflammation, superficial erosions Ingestion of aspirin or other NSAIDS, corticosteroids, alcohol, and caffeine is commonly associated with development of acute gastritis Erosive gastritis: stress-induced, occurs as complication of other life-threatening conditions like shock, severe trauma, major surgery, sepsis, burns, head injury Curling?s ulcers: follow major burn Cushing?s ulcers: follow head injury or CNS surgery Manifestations: anorexia, abdominal pain, nausea and vomiting, gastric bleeding Chronic gastritis: begins with superficial inflammation and gradually leads to atrophy of gastric tissues Type A (autoimmune): body produces antibodies to parietal cells and to intrinsic factor, they destroy gastric mucosal cells, resulting in tissue atrophy and loss of hydrochloric acid and pepsin secretion, results in pernicious anemia Type B (H.pylori infection): causes inflammation of the gastric mucosa with infiltration by neutrophils an lymphocytes; outermost layer of gastric mucosa thins and atrophies, providing less effective barrier against autodigestive properties of hydrochloric acid and pepsin NURSING DIAGNOSES Deficient fluid volume (high risk for fluid and electrolyte imbalance because of inadequate intake of food and fluids and abnormal losses of fluids and electrolytes with vomiting Tachycardia, tachypnea, and hypotension, especially orthostatic hypotension, may indicate fluid volume deficit. Electrolyte or acid-base imbalances resulting from vomiting may cause cardiac dysrhythmias or changes in respirations Imbalanced nutrition: less than body requirements Client with peptic ulcer disease Break in the mucous lining of the GI tract where it comes in contact with gastric juice Peptic ulcers: occur in any area of gastrointestinal tract exposed to acid-pepsin secretions, including esophagus, stomach or duodenum Duodenal most common Gastric more common in smokers or chronic users of NSAIDs Ulcer: break in GI mucosa, develops when the mucosal barrier is unable to protect the mucosa from damage by hydrochloric acid and pepsin, the gastric digestive juices May be chronic with spontaneous remissions and exacerbations Associated with trauma, infection, or other physical or psychological stressors Manifestations: pain (gnawing, burning, aching, or hunger-like, in epigastric region, sometimes radiating to back) Complications: hemorrhage, obstruction, perforation Obstruction may result from edema surrounding the ulcer, smooth muscle spasm, or scar tissue Symptoms: epigastric fullness feeling, accentuated ulcer symptoms, nausea Perforation: most lethal complication Gastric or duodenal contents enter the peritoneum, causing an inflammatory process an peritonitis Client has immediate, severe upper ab pain, radiating throughout abdomen and possibly to shoulder, ab becomes rigid and board-like, absent bowel sounds, signs of shock (tachycardia, diaphoresis, rapid shallow respirations) Zollinger-Ellison Syndrome: PUD caused by gastrinoma (gastrin-secreting tumor of the pancreas, stomach, or intestines) High levels of hydrochloric acid entering duodenum may also cause diarrhea and steatorrhea (excess fat in feces) from impaired fat digestion and absorption Complications: bleeding and perforation NURSING DIAGNOSES Disturbed sleep pattern Imbalanced nutrition: less than body requirements Deficient fluid volume (erosion of a blood vessel with resultant hemorrhage can lead to hypovolemia and fluid volume deficit which can lead to decrease in CO and impaired tissue perfusion Client with Gallstones Cholelithiasis: formation of stones (calculi or gallstones) within the gallbladder or biliary duct system Risk factors: age, family hx, race/ethnicity (native americans, northern Europeans), obesity, hyperlipidemia, rapid weight loss, females, biliary stasis (pregnancy, fasting, prolonged parenteral nutrition), diseases or conditions Certain very-low calorie diets are associated with a high risk of cholelithiasis. Increased cholesterol concentration in the bile and decreased gallbladder contractions associated with fasting increase the risk of gallstone formation Form when several factors interact: abnormal composition (bile is supersaturated with cholesterol, can precipitate out to form stones), biliary stasis, inflammation of gallbladder s/s: epigastric fullness or mild gastric distress after eating a large or fatty meal; stones that obstruct duct lead to distention and increased pressure behind stone biliary colic (severe, steady pain in epigastric region or RUQ of abdomen; obstruction of common bile duct may cause bile reflux into liver, leading to jaundice, pain, and possible liver damage Cholecystitis: inflammation of gallbladder Acute: usually follow obstruction of cystic duct by a stone Chronic: may result from repeated bouts of acute or from persistent irritation of gallbladder wall by stones Complications: empyema (collection of infected fluid within the gallbladder), gangrene and perforation with resulting peritonitis or abscess formation, formation of a fistula into an adjacent organ, obstruction of small intestine by large gallstone Sx: laparoscopic cholecystectomy (removal of gallbladder) NURSING DIAGNOSES Pain Imbalanced nutrition: less than body requirements (related to anorexia, pain, and nausea following meals, and impaired bile flow that alters absorption of fat and fat-soluble vitamins from the gut Risk for infection Rupture of an acutely inflamed gallbladder may be heralded by abrupt but transient pain relief as contents are released from distended gallbladder into the abdomen. Promptly report this change to the physician Liver disorders Impaired function of liver cells Impaired protein metabolism with decreased production of albumin and clotting factors Disrupted glucose metabolism and storage with resulting alterations in blood glucose levels Reduced bile production that impairs the absorption of lipids and fat-soluble vitamins Impaired metabolism of steroid hormones leads to feminization in men and irregular menses in women Jaundice: disrupted metabolism and excretion of bilirubin allows it to accumulate in tissues, leading to jaundice, yellow staining of tissues Portal hypertension: increased pressure in portal system Dilation of veins in gastrointestinal tract and abdominal wall ? esophageal varices Splenomegaly Ascites: accumulation of fluid in peritoneal cavity Portal systemic encephalopathy: impaired consciousness and mental status due to the accumulation of toxic waste products in the blood as blood bypasses the congested liver Hepatorenal syndrome: acute renal failure due to disrupted blood flow to the kidneys Client with hepatitis Hep A: infectious hepatitis, sporadic attacks or mild epidemics, transmitted via fecal-oral route via contaminate food, water, shellfish, and direct contact with infected person Hep B: can cause acute hepatitis, chronic hepatitis, fulminant (rapidly progressive) hepatitis, or a carrier state Spread thru contact with infected blood an body fluids Healthcare workers at risk thru exposure to blood and needle-stick injuries Hep C: primary worldwide cause of chronic hepatitis, cirrhosis, and liver cancer Transmitted thru infected blood an body fluids Injection drug use is primary risk factor Hep delta: goes with HBV, blood-borne Hep E: rare, transmitted by fecal contamination of water supplies in developing areas, primarily affects young adults, can cause fulminant, fatal hepatitis in pregnant women Chronic: primary cause of liver damage leading to cirrhosis, liver cancer, and liver transplantation HBV, HCV, HDV Manifestations: malaise, fatigue, hepatomegaly Fulminant: rapidly progressive, with liver failure developing with 2-3 weeks after onset of symptoms Usually related to HBV with concurrent HDV infection Toxic: many substances, including alcohol, certain drugs, and other toxins can directly damage liver cells Hepatobiliary: due to cholestasis, interruption of normal flow of bile NURSING DIAGNOSES Risk for Infection (transmission) If a client diagnosed with hep A is employed as a food handler or child care worker, contact the local health department to report possible exposure of patrons. Maintain confidentiality. Prophylactic tx of people who have possibly been exposed to the virus can prevent a local epidemic of the disease Fatigue Imbalanced nutrition: less than body requirements Disturbed body image Client with pancreatitis Inflammation of pancreas, characterized by release of pancreatic enzymes into the tissue of the pancreas itself, leading to hemorrhage and necrosis Acute: involves self-destruction of pancreas by its own enzymes thru autodigestion Interstitial edematous pancreatitis: leads to inflammation and edema of pancreatic tissue, self-limiting Necrotizing pancreatitis: more severe, inflammation, hemorrhage, and ultimately necrosis of pancreatic tissue Associate factors that may activate pancreatic enzymes: Gallstones may obstruct the pancreatic duct or cause bile reflux Alcohol causes duodenal edema and may increase pressure and spasm in the sphincter of Oddi, obstructing pancreatic outflow Tissue ischemia or anoxia, trauma or surgery, pancreatic tumors, third-trimester pregnancy, infectious agents, elevated calcium levels, hyperlipidemia S/s: abrupt onset of continuous severe epigastric and ab pain, commonly radiating to back and is relieved somewhat by sitting up and leaning forward; nausea and vomiting, abdominal distention and rigidity, decreased bowel sounds, tachycardia, hypotension, elevated temp, cold/clammy skin Complication: intravascular volume depletion with acute tubular necrosis and renal failure, acute respiratory distress syndrome (ARDS), pancreatic necrosis, abscess, pseudocysts, pancreatic ascites Chronic: gradual destruction of functional pancreatic tissue, irreversible process that eventually leads to pancreatic insufficiency Alcoholism is primary risk factor in US Malnutrition is worldwide risk factor s/s: recurrent episodes of epigastric and LUQ abdominal pain that radiates to back, nausea and vomiting, anorexia, weight loss, flatulence, constipation, steatorrhea (fatty, frothy, foul-smelling stools caused by a decrease in pancreatic enzyme secretion) complications: malabsorption, malnutrition, possible PUD NURSING DIAGNOSES Pain Imbalanced nutrition: less than body requirements Risk for deficient fluid volume (acute pancreatitis can lead to a fluid shift from the IV space into the abdominal cavity (third spacing), may cause hypovolemic shock, affecting CV function, respiratory function, renal function, and mental status)
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