GASTROINTESTINAL

SYSTEM

Gastrointestinal System/MJTayco/2009

Also known as the Gastrointestinal (GI) Tract or the Alimentary System. It is responsible for breaking down the complex food into simple nutrients the body can

absorb & convert into energy, Digestion (Digestive System).

Hepatobiliary System (Accessory Digestive Organs)

Anatomy & Physiology Overview of the Gastrointestinal System

Structure & Histology Gastrointestinal System is a 23 26-foot-long pathway that extends from the mouth, esophagus, stomach, small & large intestines, & rectum, to the terminal structure, the anus. The GIT consists of a hollow muscular tube surrounded by four tissue layers. Lumen: the inner wall of the GIT consists of four layers/tunics. 1. MUCOSA (A tissue which produce mucus) The innermost layer. Includes a thin layer of smooth muscle and specialized exocrine gland cells. Surrounded by the submucosa. a. Mucous Epithelium Mouth, Esophagus, & Anus (resists abrasion) Stomach & Intestines (absorbs and secretes) b. Lamina Propria, a loose connective tissue c. Muscularis Mucosa, a thin smooth muscle layer 2. SUBMUCOSA Lies just outside the mucosa. A thick layer of loose connective tissue containing nerves, blood vessels, and small glands. Plexus is an extensive network of nerve cell processes and is innervated by autonomic nerves. Surrounded by the muscularis. 3. MUSCULARIS Found in most parts of the digestive tube consisting of: a. Circular Smooth Muscle, inner layer b. Longitudinal Smooth Muscle, outer layer Enteric Plexus is another nerve plexus also innervated by autonomic nerves between the two muscle layers. Extremely important in the control of movement and secretion within the tract. Work to keep contents moving through the tract. 4. SEROSA The outermost layer. Composed of connective tissue. a. Serosa The underlying connective tissue of the Peritoneum (a smooth epithelial layer). b. Adventitia (coming from outside) The connective tissue layer covering regions of the digestive tract not covered by peritoneum which is continuous with the surrounding connective tissue. Although the GIT is continuous from the mouth to the anus, it is divided into specialized regions. The mouth, pharynx, esophagus, stomach, and small and large intestines each perform a specific function. In addition, the secretions of the salivary, gastric, and intestinal glands; liver; and pancreas empty into the GIT to aid digestion. Functions 1. Take in food (INGESTION). Food and water are taken into the body through the mouth. Food and fluids are ingested, swallowed, and propelled along the lumen of the GIT to the anus for elimination. The smooth muscles contract to move food from the mouth to the anus. 2. Break down the food (DIGESTION). The food that is taken into the body is broken down during the process of digestion from complex molecules to smaller molecules that can be absorbed.

Before can be absorbed, it must be broken down to a liquid, called Chyme. The mechanical and chemical process whereby complex foodstuffs are broken down into simpler forms that can be used by the body. a. The Stomach secretes hydrochloric acid. b. The Liver secretes bile. c. The Digestive enzymes are released from accessory organs, aiding in food breakdown. Metabolism: Consists of the sum of all physical & chemical changes that take place within an organism. Catabolism: Series of chemical reactions that take place within the cell; breaks down food molecules to produce energy. Anabolism: Synthesis of compounds from simpler compounds. 3. Absorb digested molecules (ABSORPTION). The small molecules that result from digestion are absorbed through the walls of the intestine for use in the body. Takes place after digestion is complete. Carried out as the nutrients produced by digestion move from the lumen of the GIT into the bodys circulatory system for uptake by individual cells. Active Transport via intestinal cells. Water & solutes move through the intestinal mucosa in opposite direction expected in osmosis & diffusion. 4. Provide nutrients. The process of digestion and absorption provides the body with water, electrolytes, and other nutrients such as vitamins and minerals. 5. Eliminate wastes (ELIMINATION). Undigested material, such as fiber from food plus waste products excreted into the digestive tract are eliminated in the feces.

Gastrointestinal System/MJTayco/2009

I. THE MOUTH (The Oral Cavity)

Structure

The first part of the GIT. It includes the buccal mucosa, cheeks, lips, tongue, hard palate, soft palate, teeth, and salivary glands. 1. Lips are muscular structures. Important in the process of Mastication (chewing). 2. Cheeks They help manipulate the food within the mouth and hold the food in place while the teeth crush or tear it. Mastication begins the process of mechanical digestion, in which large food particles are broken down into smaller ones. 3. Buccal Mucosa is the mucous membrane lining the inside of the mouth. 4. Tongue is a large muscular organ that occupies most of the oral cavity. The tongue moves foods in the mouth and, in cooperation with the lips and cheeks, holds the food in place during mastication. Plays a major role in the process of Swallowing. The major sensory organ for taste. 5. Teeth Located in the mandible and maxillae. 4 Quadrants: Right Upper, Left Upper, Right Lower, Left Lower. Each quadrant contain the following: a. Incisor to cut(1) Central (1) Lateral b. Canine dog c. Premolars (1st) (2nd) d. Molars millstone (1st) (2nd) (3rd)

Gastrointestinal System/MJTayco/2009

late teens or early twenties when the person is old enough to have acquired some degree of wisdom. Permanent/Secondary Teeth 32, adult Primary/Deciduous Teeth (Milk Teeth), 20, childhood

Wisdom Teeth, are the third molars, they usually appear in a persons

a. Crown i. Cusps one or more points b. Neck c. Root 1. Pulp Cavity center of the tooth which is filled with blood vessels. 2. Dentin a living, cellular, bonelike tissue surrounding the pulp. 3. Enamel an extremely hard, acellular substance covering the dentin of the tooth crown which protects the tooth against abrasion and acids produced by bacteria in the mouth. Enamel is nonliving and cannot repair itself. Formation of dental caries/tooth decay is the result of the breakdown of enamel by acids produced by bacteria on the tooth surface. 4. Cementum covering the dentin in the root which helps anchor the tooth in the jaw. 5. Alveoli in which the teeth are rooted along the alveolar process of the mandible and maxillae. 6. Gingiva a dense, fibrous connective tissue and moist stratified squamous epithelium covering the alveolar process. 7. Periodontal Ligaments connective tissue fibers that extend from the alveolar walls and are embedded into the cementum which hold the teeth in place. 6. Palate Roof of the oral cavity Separates the oral cavity from the nasal cavity and prevents food from passing into the nasal cavity during chewing and swallowing. a. Hard Palate The anterior part consisting of bone. b. Soft Palate The posterior portion consisting of skeletal muscle and connective tissue Uvula is a posterior extension of the soft palate. Tonsils located in the lateral posterior walls of the oral cavity, nasopharynx, and posterior surface of the tongue. 7. Salivary Glands Produces saliva Saliva a mixture of serous (watery) and mucous fluids. It helps keep the oral cavity moist and contains enzymes that begin the process of chemical digestion. a. Parotid Glands The largest glands Serous glands located just anterior to each ear. Enters the oral cavity adjacent to the second upper molars. b. Submandibular Produces more serous than mucous secretions. Each gland can be felt as a soft lump along the inferior border of the mandible. Opens into oral cavity on each side of the frenulum of the tongue. If the mouth is opened and the tip of the tongue is elevated, saliva can squirt out of the mouth from the ducts of these glands. c. Sublingual The smallest of the three paired salivary glands. Produced primarily of the mucoid secretions. They lie immediately below the mucous membrane in the floor of the oral cavity. Each has 10 12 small ducts opening onto the floor of the oral cavity.
Mastication Mastication breaks large food particles into small ones, which have a much larger total surface area than a few large particles would have. Food in the mouth is chewed/masticated by the teeth. The incisors and canine primarily cuts and tear food. The premolars and molars primarily crush and grind it. The digestive enzymes act on molecules only at the surface of the food particles, mastication increases the efficiency of digetsion

Parts of the Tooth:

Gastrointestinal System/MJTayco/2009

8. Pharynx Throat Connects the mouth with the esophagus. a. Nasopharynx b. Oropharynx posterior walls are formed by the superior, middle, and inferior c. Laryngopharynx pharyngeal constrictor muscles, transmit food 9. Esophagus A muscular tube, lined with moist stratified squamous epithelium that extends from the pharynx to the stomach. 25 cm long.

Location:

Lies anterior to the vertebrae and posterior to the trachea within the mediastinum. Passes through the diaphragm and ends at the stomach.

a. Transport food from the pharynx to the stomach. b. Regulate the movement of food into and out of the esophagus (Upper & Lower Esophageal Sphincters located at upper and lower ends of the esophagus.) c. Cardiac Sphincter the lower esophageal sphincter Numerous mucous glands produce thick, lubricating mucus that coats the inner surface of the esophagus. The food is then swallowed & transported down into the esophagus through the rhythmic contraction of muscles known as peristalsis.

Function:

Functions 1. An integral part of digestion, speech, & breathing.

Deglutition Deglutition or Swallowing can be divided into three separate phases: 1. Voluntary Phase A bolus or mass of food is formed in the mouth. The bolus is pushed by the tongue against the hard palate, forcing the bolus toward the posterior part of the mouth and into the oropharynx. 2. Pharyngeal Phase A reflex that is initiated when a bolus of food stimulates receptors in the oropharynx. Begins with the elevation of the soft palate, which closes the passage between the nasopharynx and oropharynx. The pharynx elevates to receive the bolus of food from the mouth. 3 Pharyngeal Constrictor Muscles contract in succession, forcing the food through the pharynx with the upper esophageal sphincter relaxes, and food is pushed into the esophagus. Epiglottis tipped posteriorly as food passes through the pharynx so that the opening into larynx is covered, preventing food from passing into the larynx. 3. Esophageal Phase Responsible for moving food from esophagus to the stomach. Peristaltic Wave muscular contractions of the esophagus. Relaxation of the circular esophageal muscles precedes the bolus of food

II. THE STOMACH

The stomach is a muscular, saclike organ that connects the esophagus and small intestine. Location: Left side of the body, under the diaphragm Function: break down food.

Gastrointestinal System/MJTayco/2009

1. 2. 3. 4.

Gastric Secretions

Pepsinogen, by chief cells; fundus; CHON HCl, by parietal cells; CHON; response to Gastrin Intrinsic Factor, by parietal cells; absorption of Vit.B12 Mucoid Secretions, coat stomach wall; prevent autodigestion

1. Cephalic Phase, the secretion of digestive juices is stimulated by smelling, tasting, & chewing food. 2. Gastric Phase, stimulated by the presence of food in the stomach (Neural stimulation = PNS) (Hormonal stimulation = Gastrin by Gastric mucosa) Chyme, food bolus, S.I via duodenum

Phases

Sphincters Divisions

1. Cardiac: between esophagus & stomach 2. Pyloric: between stomach & duodenum

1. Fundus 2. Body 3. Antrum III. PANCREAS

Fish-shaped gland Location: Lies retroperitoneally in the upper abdominal cavity behind the stomach and extends horizontally from duodenal C-loop to the spleen. (Common Bile Duct) Division: Head, Body, & Tail Functions:

It is a heterocrine gland because it performs both exocrine and endocrine functions. 1. Exocrine Cells (Pancreas) (80%) Acinar Cells which secretes the enzymes that are necessary for the digestion of a. Trypsinogen & Chymotrypsin CHON Digestion b. Amylase Carbohydrates Starch (Disaccharides) c. Lipase Fat Digestion Vagal stimulation and release of the hormones secretin and CCK control the rate and the amount of pancreatic secretion. 2. Endocrine (Islets of Langerhans) (<2%) Regulate Blood-Sugar level. a. Alpha Cells Glucagon, which stimulates glycogenolysis in the liver. b. Beta Cells Insulin, which promotes carbohydrate metabolism.

Gastrointestinal System/MJTayco/2009

IV. LIVER

Largest internal organ in humans. Location: Right Hypochondriac & Epigastric regions (right upper quadrant) Division: 1. Right Lobe larger 2. Left Lobe smaller Liver (Hepatic) Lobules: Functional units composed of Hepatic cells 1. Central Vein 2. Hepatic Plates 3. Bile Canaliculi 4. Venous Sinusoids Blood (Venous Sinusoids) Central Vein Hepatic Vein Inferior Vena Cava Liver Sinusoids (capillaries): Lined with Kupffer Cells, the phagocytic cells of the reticuloendothelial system. Thus, the blood is cleansed of bacteria and other foreign products. (Phagocytosis)

1. Portal Vein two-thirds of the blood supply to the liver come from the portal vein, thus it receives mostly unoxygenated blood. 2. Hepatic Artery Portal Circulation: brings blood to the liver from stomach, spleen, pancreas, & intestines Functions: The liver performs more than 400 functions in three major categories (storage, protection, and metabolism) 1. Metabolism of CHO, CHON, and Fats: Oxidizes nutrients for energy & produces compounds that can be stored. a. Carbohydrate Metabolism Livers role in carbohydrate metabolism involves storing and releasing glycogen as the bodys energy requirements change. i. Glycogenesis (formation and storage of glucose to glycogen) ii. Glycogenolysis (breakdown of glycogen to glucose) iii. Gluconeogenesis (breakdown of fats and protein into glucose) iv. Removes excess glucose from circulation and stores it until it is needed.

Blood Supply:

Metabolism of CHON by the liver is considered vital for human survival. i. CHON Catabolism: It breaks down amino acids to remove ammonia, which is the converted to urea and is excreted via the kidneys. ii. CHON Synthesis: Albumin, Alpha and Beta Globulins, Clotting Factors, CReactive CHON, Transferrin, Enzymes. c. Fat Metabolism i. Oxidation of fatty acids for energy. ii. Ketone formation. iii. Synthesis of cholesterol and phospholipids. iv. Formation of lipoproteins. 2. Liver forms and continually secretes bile. i. Secretion of Bile, chief digestive function, a solution critical to fat emulsion and absorption. ii. The secretion of bile increases in response to gastrin, secretin, and cholecystokinin. 3. Conjugation & Excretion (Form of glycogen, fatty acids, mineral, fat-soluble & H2O-soluble vitamins) of Bilirubin. 4. Storage of Vitamins and Minerals, such as the following: i. Copper, Iron, Magnesium ii. Vitamin B2, B12, Vitamin B6, Folic Acid iii. Fat-soluble vitamins (A, D, E, K) 5. Protective function involves phagocytic Kupffer Cells, which are part of the bodys reticuloendothelial system. They engulf harmful bacteria and anemic red blood cells. 6. Converts excess amino acids into useful forms and filters drugs and poisons from the bloodstream, neutralizing them and excreting them in bile. 7. Detoxification of endogenous and exogenous substances, e.g., ammonia, steroids, drugs. 8. Excretion of adrenal cortex hormones (glucocorticoid, mineralocorticoid, like Aldosterone, sex hormones). 9. Produce heparin. 10. Can lose 75 percent of its tissue (to disease or surgery) without ceasing to function. 11. Blood reservoir. Physiologic changes of the liver with aging; 1. Decrease in size of the liver. 2. Decrease in enzymes involved in the metabolism with drugs. 3. Increased propensity to drug toxicity.

b. Protein (CHON) Metabolism

Gastrointestinal System/MJTayco/2009

V. GALLBLADDER

A pear-shaped bulbous sac. Location: Under & Attached to the Liver Division/Portion: 1. The Neck continuous with the cystic duct.

It is drained by the cystic duct, which joins with the hepatic duct from the liver to form the common bile duct. Ductal System: Provides Route for Bile to reach the intestines Bile formation (Liver) Hepatic Duct + Cystic Duct (drains the gallbladder) Common Bile Duct Function: 1. Collects, Concentrates & Reservoir for bile. i. The liver produces 600 1200 ml of bile at a time. ii. Water = 90% - 95%, which is absorbed by the mucous membrane lining the gallbladder. iii. The gallbladder stores 50 70 ml of concentrated bile. iv. Bile is a greenish liquid composed of water, cholesterol, bile salts, electrolytes, and phospholipids. v. Bile is important in fat emulsification and intestinal absorption of fatty acids, cholesterol, and other lipids. vi. Bile also aids in excretion of conjugated Bilirubin (an end product of hemoglobin degradation) from the liver and prevents jaundice. 2. Presence of fat in acidic chyme transported into the duodenum causes secretion of cholecystokinin (CCK). CCK causes gallbladder contraction and relaxation of the sphincter of Oddi, releasing bile into the common bile duct for delivery to the duodenum. 3. Sphincter of Oddi: Relaxed (Bile enters Duodenum) Contracted (Bile is stored in Gallbladder)

2. The Body main portion. 3. The Fundus the lower bulbous section.

Gastrointestinal System/MJTayco/2009

VI. THE SMALL INTESTINE

Approx. 20 to 25 feet long 1. Duodenum (first, 10-12 inches) 2. Jejunum (the middle, 8-10 feet) 3. Ileum (the distal, 12 feet). Most digestion takes place. Responsible for absorbing nutrients from the chyme (semi-liquid mass of partially digested food). Inner lining or Mucosa is folded & covered with tiny finger-like projections called villi, a design that maximizes the absorptive surface area of the intestine. Rhythmic contraction of the muscular walls moves food along while bile, enzymes, & secretions break it down. Nutrients absorbed into the intestines many blood vessels are carried to the liver to be distributed to the rest of the body.

Divisions

VII. THE LARGE INTESTINE

Gastrointestinal System/MJTayco/2009

Also known as the colon.

1. Cecum, Ascending/Transverse/Descending/Sigmoid Colon 2. Rectum 3. Anus Anchored in the abdomen, final section of the digestive tract. The last 5 inches of the large intestine comprise the Rectum. The distal end of the rectum forms the Anal canal composed of muscles that control defecation. The opening to the anal canal is called the Anus.

Divisions

1. Internal Sphincter (involuntary) 2. External Sphincter (voluntary) Responsible for absorbing water, electrolytes, and salts. Undigested material passes from the small intestine as liquid & fiber. The muscular walls of the large intestine push this material through the intestine into the rectum. Cells in the smooth walls absorb vitamins, minerals, & water. Microorganisms are responsible for small amount of further breakdown & make some vitamins. Amino acids, deaminated by bacteria Ammonia Urea(Liver)

Sphincters

Vitamin K & some B, synthesized

Condensed waste, called Feces (75 % H2O, 25% solid wastes), leaves the body through the rectum and anal canal.

Assessment Gastrointestinal System

I. HEALTH HISTORY Goal: To determine the events related to the current health problem. Gordons Functional Health Patterns Nutritional-metabolic and elimination patterns which is a method used to assess GI functioning. Nutritional-Metabolic Pattern Elimination Pattern What is your typical daily food What is your usual bowel intake? Describe a days meals, elimination pattern? Frequency? snacks, and vitamins. Character? Discomfort? How much salt do you typically add Laxatives? to your food? Do you use salt Do you have any pain or bleeding substitutes? associated with bowel movements? How is your appetite? Any recent Have you experienced any changes change? in your usual bowel pattern? Do you have any difficulty chewing or When was your last rectal swallowing? examination? Do you wear dentures? How well do Have you ever had an endoscopy they fit? or a colonoscopy? Do you ever experience indigestion or What is your usual urinary heartburn? How often? What elimination pattern? Frequency? seems to cause it? What helps it? Amount? Color? Odor? Control? Do you have pain, diarrhea, gas, or Have you noticed a change in the any other problems? Do any specific amount of urine? foods cause this for you? What is your typical daily fluid intake? What types of fluids (water, juices, softdrinks, coffee, tea)? How much?

Gastrointestinal System/MJTayco/2009 10

Have you had any recent change in your weight? Weight gain? Weight loss? How much? Have you noticed a change in the tightness of your rings or shoes? Tighter? Looser? Have you noticed any difference in the size of your abdomen?

A. Demographic Data

B. C.

D.

E.

Age Gender This information can provide information regarding predispositions Culture to particular GI system disorders. Occupation Family History and Genetic Risk Some GI health problems have a genetic predisposition. Presenting Problem 1. Mouth: Dental carries, Bleeding gums, Salivation, difficulty chewing 2. Ingestion Anorexia or Hyperorexia (food preferences) Food Intolerance (allergy, fatty, fluids) Weight (within 2 9 months) Dysphagia (level of sensation) (w/ or w/o foods of fluids) Nausea (onset & duration) (assoc. Sx) (ac or bc) Vomiting (onset & duration) (assoc. Sx) Regurgitation/Reflux (w/ ingestion) (assoc. Sx) (positions) 3. Digestion Dyspepsia/Indigestion (location) (time) (assoc. foods & Sx) Pyrosis/Heartburn (location) (time) (ac or bc) (assoc. foods & Sx) (pain) Pain character, frequency, location, duration, distribution, aggravating Sx PQRST i. Precipitating or Palliative 1. What brings it on? 2. What makes it better? Worse? 3. When did you first notice it? ii. Quality or Quantity 1. How does it look, feel, or sound? 2. How severe/intense is it? iii. Region or Radiation 1. Where is it? 2. Does it spread anywhere? iv. Severity or Scale 1. How bad is it? (on a scale of 1-10) 2. Is it getting better, worse, or staying the same? v. Timing 1. Onset (Exactly when did it first occur?) 2. Duration (How long did it last?) 3. Frequency (How often does it occur?) 4. Elimination/Bowel Habits Constipation (#stools/day or week) (size/color) (food/fluid intake) (+ tenesmus) (assoc. Sx) Diarrhea (#stools/day) (consistency/quantity/odor) (interference w/ ADL) (assoc. Sx) Lifestyle 1. Eating Behaviors Rapid Ingestion Skipping Meals Snacking 2. Cultural/Religious Values Vegetarian Kosher 3. Alcohol Ingestion 4. Smoking Medications

1. Antacids, Antiflatulents, Antiemetic 2. Vitamin Supplements 3. Aspirin & Anti-inflammatory F. Past Medical History 1. Childhood, Adult, Psychiatric Illnesses 2. Surgery 3. Bleeding Disorders 4. Menstrual Hx 5. Exposure to infectious agents 6. Allergies

Gastrointestinal System/MJTayco/2009 11

II. PHYSICAL ASSESSMENT A. Mouth (inspect/palpate) 1. Outer/Inner Lip (color) (lesions) (nodules) (symmetry) 2. Buccal Mucosa (redness) (pallor) (swelling) (lesions) (ulcerations) 3. Teeth (dental caries) (dentures) (missing/broken teeth) 4. Gums (redness) (pallor) (ulcers) (bleeding) 5. Tongue (color) (ulcers) (abnormal coating) (swelling) (deviation) (movement) (moisture) 6. Palates [hard & soft] (color) 7. Pharynx (tonsil abnormalities) (lesions) (ulcers) (uvular deviation) (unusual mouth odor) B. Abdomen Position: Supine with knees flexed (Dorsal Recumbent Position) Sequence: Inspection, Auscultation, Percussion, Palpation (IAPP) Alert! Auscultation is performed in the abdomen before percussion and palpation because they can increase intestinal activity and therefore alter bowel sounds. Alert! NO abdominal palpation is done in clients with tumor of the liver or kidney to prevent rupture of tumor and massive internal hemorrhage. Inspection 1. Inspect Skin a. Condition skin should be smooth, intact b. Contour flat, concave, rounded or distended depending on the clients body type. 2. Inspect Umbilicus (shape) (position) (color) concave, located at midline, same color as the abdominal skin. 3. Inspect Movement (peristalsis) (pulsations) normally, peristaltic movements are not visible. Auscultation 1. Peristaltic Sounds Normal: bubbling, gurgling (5 30 times/minute) : diarrhea, gastroenteritis, early intestinal obstruction : constipation, late intestinal obstruction, anticholinergics, post-op anesthesia Note: Empty bladder before auscultation of the abdomen because a full bladder can interfere with sounds. Percussion To determine the size and location of abdominal organs and to detect fluid, air and masses. Alert! Avoid abdominal percussion in clients with suspected abdominal aneurysms and in those clients with abdominal organ transplants. 1. Tenderness/Masses (determine distribution of tympany & dullness Stomach: (normal tympany) Spleen: (normal tympany) (dullness if enlarged) Small/Large Intestine: (normal tympany) Bladder: (normal tympany) (dullness if full) Palpation Palpate abdomen by lightly depressing (1-2 cm) the abdomen in quadrant to quadrant manner. 1. Light Palpation (1cm) (areas of tenderness) (muscle guarding) (masses) 2. Deep Palpation (4 8cm) (rigidity) (masses) (tenderness) (spleen) Should be performed cautiously only by a skilled nurse.

Hepatobiliary System

Gastrointestinal System/MJTayco/2009 12

A. HISTORY 1. Chief Complaint a. Abdominal pain b. Anorexia c. Nausea and vomiting d. Weight loss e. Stool changes f. Food intolerance g. Altered level of consciousness h. Urine changes i. Jaundice, pruritus j. Bleeding tendencies k. Ascites l. Edema of the limbs m. Fatigue, fever 2. Past Medical History a. Major illnesses or hospitalizations b. Recent skin/mucous membrane disruptions i. Ear piercing, tattooing, blood transfusion, dental procedures c. Medications i. Hepatotoxic drugs (acetaminophen, INH, sulfonamides, thiazide, diuretics, arsenic, methotrexate d. Family History i. Cancer of the liver, hepatitis, alcoholism, obesity e. Psychosocial History and Lifestyle i. Occupation and Work Environment Close contact with hazardous waste or polluted water Travel in Hepatitis/Pancreatitis endemic areas Consumption of raw/steamed shellfish from polluted water Contact with hepatitis-infected people or animals Exposure to dry-cleaning fluids ii. Habits Food preference Meat preparation Use of alcohol B. PHYSICAL EXAMINATION 1. General appearance and health status (jaundice, obviously ill or impaired) 2. Nutritional status 3. Assess abdomen (examine painful area last)

Diagnostic

StudIes

Gastrointestinal System
I. LABORATORY TESTS A. CEA (Carcinoembryonic Antigen) (+) in colorectal Cancer Avoid heparin for 2 days Specimen is obtained by venipuncture B. D-Xylose Absorption Test Initial blood/urine specimen are collected NPO for 10 12 hours Blood/urine levels are measured Done for diagnosis of malabsorption C. Exfoliative Cytology Done to detect malignant cells Written consent is obtained Liquid diet is given Upper GI: NGT insertion is done Lower GI: laxative the night before and enema in the morning Cells are obtained from saline lavage via NGT for UGI/via Proctoscope for LGI II. FECAL STUDIES A. Occult Blood (Guaiac Stool Exam) Done to detect GI bleeding.

Done by placing hydrogen peroxide to the stool specimen. formed, this indicates bleeding.

Gastrointestinal System/MJTayco/2009 13

If blue ring is

1. Provide high-fiber diet for 48 72 hours. 2. NO red meats, poultry, fish (contain hemoglobin fibers which may be mistaken as blood), turnips, horseradish, cauliflower, broccoli and melon (high in peroxidase and will cause false positive result). 3. Vitamin C causes false negative reading. 4. Withhold for 48 hours: Iron, Steroids, Indomethacin, Colchicine Iron causes blackish/greenish discoloration of stool. This may be mistaken as bleeding. Steroids, Indomethacin, Colchicine may cause GI irritation thereby, bleeding. This cause false positive result. 3 stool specimen will be collected (3 successive days) B. Stool for Ova or Parasites Send fresh, warm stool specimen, especially if the purpose of the test is to detect amoebiasis. C. Stool Culture Use sterile test tube and cotton-tipped applicator to collect specimen. This ensures that the specimen is not contaminated. D. Stool for Lipids Done to assess steatorrhea. Include fats in the diet. To assess the ability of the GI to metabolize fats. Avoid alcohol for 3 days. Alcohol mobilizes fats. This will cause false positive result. 72-hour stool specimen is collected. Store the specimen on ice. Avoid mineral oil, neomycin SO4 and other oily medications. III. BARIUM SWALLOW (upper GI series) Fluoroscopic examination to determine structural problems & gastric emptying time Swallow Barium SO4 or other contrast medium Sequential films taken as it moves through the system

Pre-Test Nursing Care

1. NPO after midnight (6 8 hours prior) 2. Barium will taste chalky

Pre-Test Nursing Care

1. Laxatives [To enhance elimination of Barium & prevent obstruction/impaction] IV. BARIUM ENEMA (lower GI series) To identify structural abnormalities of the colon Barium is instilled into the colon by enema Client retains the contrast medium while X-rays are taken

Post-Test Nursing Care

1. 2. 3. 4.

Pre-Test Nursing Care

NPO 8 hours pre-test Enemas until clear in AM Laxative or suppository Cramping may be experienced

1. Laxatives & Fluids (expel Barium) V. ESOPHAGOGASTRODUODENOSCOPY Direct visualization of esophagus, stomach, duodenum by insertion of lighted fibroscope To observe structures, ulcerations, inflammation, tumors May include biopsy

Post-Test Nursing Care

Pre-Test Nursing Care

NPO 6 8 hours pre-test Consent form Local anesthesia [To ease discomfort] No speaking Hoarseness & sore throat for several days

1. NPO until gag reflex return 2. Assess VS, pain, dysphagia, bleeding 3. Warm NSS for sore throat

Post-Test Nursing Care

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VI. COLONOSCOPY Endoscopic visualization of colon May include biopsy or removal of foreign substances

Pre-Test Nursing Care

NPO 8 hours pre-test Laxatives 1 3 days before the exam Enemas a night before Consent form Feeling of pressure might be experienced

1. Observe for rectal bleeding & signs of perforation 2. Planned rest periods VII. SIGMOIDOSCOPY Endoscopic visualization of sigmoid colon Identify lesions or inflammation or remove foreign body

Post-Test Nursing Care

1. Light supper & light breakfast 2. Bowel prep. 3. Urge to defecate or abdominal cramping may be experienced

Pre-Test Nursing Care

1. Signs of bowel perforation VIII. GASTRIC ANALYSIS Insertion of nasogastric tube to examine fasting gastric contents for acidity & volume

Post-Test Nursing Care

1. NPO 6 8 hours pre-test 2. NO smoking, anticholinergic, antacids for 24 hours pre-test 3. Expectorate saliva [To prevent buffering of secretions]

Pre-Test Nursing Care

1. Frequent mouth care

Post-Test Nursing Care

Hepatobiliary System
A. FAT METABOLISM Serum Total Cholesterol and Cholesterol Esters Normal Range: 140 220 mg/dl (Hepatocellular Damage) (Biliary Obstruction) B. SERUM PHOSPHOLIPIDS Normal Range: 150 250 mg/dl (Hepatocellular Damage) (Biliary Obstruction) C. PROTEIN METABOLISM 1. Total Serum Protein (Hepatocellular Damage) 2. Immunoglobulins IgA, IgG ( - Liver Cirrhosis) IgG ( - Chronic Active Hepatitis Biliary Cirrhosis) IgM ( - Hepatitis A) 3. BUN (Severe Hepatocellular Disease Obstruction of portal venous flow) 4. Protime; PTT, APTT (Hepatocellular Damage Increase risk of bleeding) 5. Blood Ammonia Levels Normal Value: 75 ug/dl (Severe Hepatocellular Damage) causes Hepatic Encephalopathy D. BILIRUBIN METABOLISM 1. Total Serum Bilirubin

2. 3. 4.

5.

6.

Normal Value: 0.1 1 mg/dl (Hepatocellular Damage) causes Jaundice Conjugated/Direct Bilirubin (Biliary Obstruction) Unconjugated/Indirect Bilirubin (Hemolysis of RBC & Hepatocellular Damage) Urine Bilirubin (Foam Test) Conjugated Bilirubin in urine (Hepatocellular/Obstructive Biliary Disease) Unconjugated bilirubin is not excreted in the urine because it is not water soluble. Urine Urobilinogen Normal Value: 0.2 1.2 units (Obstructive Biliary Disease) (Hepatocellular Damage) Fecal Urobilinogen (Stercobilin) (Hemolysis of RBC) Absence of fecal urobilinogen (Obstructive Biliary Disease) causes acholic stool which is pale/gray/clay-colored stool)

Gastrointestinal System/MJTayco/2009 15

E. SERUM ENZYMES 1. AST/SGOT 2. ALT/SGPT Most specific indicator of liver function 3. LDH 4. GGT (Gamma Glutamyl Transpeptidase) (Liver cirrhosis is alcohol induced) 5. Alkaline Phosphatase a. Slight Moderate Elevation (Hepatocellular Disease) b. Severe Elevation (Obstructive Biliary Disease) F. ULTRASOUND of the LIVER

Preparation a. NPO 8 12 hours b. Laxative the night before the procedure c. Adequate hydration

G. ORAL CHOLECYSTOGRAM a. Injection of radiopaque dye & X-ray examination b. To visualize gallbladder c. To determine gallbladders ability to concentrate & store the dye d. To assess patency of biliary duct system e. Pre-Test Nursing Care a. Low-Fat Meal: NOC before the test b. Black Coffee, Tea, H2O: AM of exam c. Check for Iodine Sensitivity d. Administer Dye tablets (Telepaque) as ordered Post-Test Nursing Care a. Observe for S.E. of dye [NV] [Diarrhea] H. LIVER BIOPSY (Closed Needle) Invasive procedure where a specially designed needle is inserted into the Liver To remove a small piece of tissue for study Pre-Test Nursing Care a. Consent form b. NPO 6 8H c. Vitamin K injection d. Monitor Protime; initial VS e. Instruct to Hold breath during biopsy (5 10 seconds) [To prevent trauma to the diaphragm]. f. Position client to the left side Post-Test Nursing Care a. VS every 30 minutes to every hour for the first 24 hours. b. Place client on RIGHT side for few hours (4 hours) with Pillow against Abdomen [Provide pressure on the Liver and prevent bleeding] c. Bed rest for 24 hours.

d. Observe puncture site for hemorrhage e. Assess for complications of shock & pneumothorax I. PARACENTESIS (Peritoneal Tap)

Gastrointestinal System/MJTayco/2009 16

Pre-Test Nursing Care a. Consent form b. Initial VS c. Ask client to empty bladder [To prevent puncture] d. Check serum protein studied [If levels are low, procedure may be postponed]. e. Place client on sitting/upright position. Post-test Nursing Care a. Assess VS b. Assess urine output c. Assess for rigidity of the abdomen d. Assess for signs and symptoms of bleeding, peritonitis, hypovolemic shock

[Potential complications of paracentesis].

J. ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP) Direct visualization with radiographic examination of the liver, gallbladder, and the pancreas. Contrast medium is induced via an upper GI endoscopy, as X-rays are taken simultaneously.

Pre-Test Nursing Care a. Consent form b. NPO 10 12 hours c. Check for allergy to iodine/seafoods d. Initial VS e. Atropine Sulfate; Valium as ordered f. Local anesthetic to the throat g. Place on left side. Post-Test Nursing Care a. NPO until gag reflex returns b. Turn to side [To prevent aspiration]. c. Monitor VS d. Monitor for signs and symptoms of sepsis, perforation, and pancreatitis.

Gastrointestinal
I. ENEMAS

Interventions

Definition: Instillation of fluid into the rectum Purpose: Stimulate Defecation Types

1. Cleansing Enema Tap H2O, NSS, Soap

Indication/Uses:

Constipation or Fecal Impaction Bowel Cleansing prior Dx procedure/Surgery Establish regular bowel function 2. Retention Enema Mineral Oil, Olive Oil, Cottonseed Oil

Indication/Uses:

Lubricate or soften hard fecal mass

Nursing Care

Cleansing Enema: a. Explain procedure b. Mouth breathing [To relax abdominal musculature & avoid cramps] c. Adequate time is needed to defecate d. Prep. Solution at 1050 1100F e. Ready bedpan, commode, bathroom f. Position client & drape adequately g. Waterproof pad under buttocks

h. Lubricate tube & allow solution to fill tubing displacing air i. Insert rectal tube 4 5 inches without using force (request several deep breaths) j. Administer 500 1000 ml of solution over 5 10 minutes (if cramping occurs, slow the speed) k. Have the client retain solution until the urge to defecate becomes strong l. Document amount, color, characteristics of stool & clients reaction m. Assess for dizziness, light-headedness, abdominal cramps & nausea n. Monitor electrolytes with repeated enemas Retention Enema: (Same as cleansing except) a. Oil is used instead of H2O b. Administer 150 200 ml c. Retain oil for at least 30 minutes II. GASTROSTOMY Definition: Insertion of catheter through an abdominal incision into the stomach secured with sutures Purpose: Alternative method of feeding (temporary or permanent)

Gastrointestinal System/MJTayco/2009 17

a. Maintain skin integrity Inspect & cleanse skin around stoma frequently Keep deep area dry [To avoid excoriation] b. Maintain patency of the tube Assess residual before each feeding (check orders) Irrigate before & after each feeding Measure/record drainage c. Promote adequate nutrition High-Fowlers position Keep HOB elevated 30 minutes after meals [To prevent regurgitation] Feeding at room temp. Prescribed amount of feeding in prescribed amount of time Weigh daily Monitor I&O; signs of DHN III. NG TUBES

Nursing Care

1. Levin: single- lumen, nonvented 2. Salem: tube within a tube, vented [To provide constant inflow of air]

Definition: Soft rubber or plastic tube inserted through a nostril & into the stomach Purpose: Gastric decompression, Feeding, Obtaining specimen Types: Nursing Care

a. Insertion of the tube Explain purpose of tube & procedure Measure the tube (tip of nose earlobe tip of xiphoid) Instruct to bend head forward if possible b. Monitor functioning of system & ensure patency Signs of Malfunction: abdominal discomfort, NV, no drainage Assess position: aspirate gastric contents to confirm [Inject 10 ml air via tube & auscultate for rapid reflux] Check if free of kinks; irrigate as ordered Record amount, color, & odor of drainage c. Ensure maximal comfort H2O soluble lubricant to lips [To prevent dryness] Nares free from secretions Periodic warm NSS gargles [To prevent dryness] Frequent mouth care If allowed, give hard candy or gum [To stimulate saliva & prevent dryness] Elevate head & chest during/1 2 hours after feedings [To prevent reflux] d. Maintain F&E balance Assess for signs of metabolic alkalosis [Suctioning causes excessive loss of HCl & K] IVF as ordered If suction used, irrigate NG tube with NSS [To Na loss] If suction used, ice chips sparingly [To avoid dilution of electrolytes] I&O

Gastrointestinal System/MJTayco/2009 18

Monitor lab values & electrolytes

IV. INTESTINAL TUBES Definition: Tube is inserted via nostril through stomach & into the intestine Purpose: Decompression proximal to obstruction, Relief of obstruction, Decompression of post-op edema at surgical site

1. Cantor Tube: single-lumen 2. Harris Tube: single-lumen 3. Miller-Abbott: double lumen Nursing Care a. Facilitate placement of tube High-fowlers Right side [To aid in advancing tube (stomachduodenum)] Continuously monitor tube markings Tape tube in place only after placement in duodenum is confirmed b. Maximal comfort, as for NG tube V. OSTOMIES

Types

Types of Ostomies

1. Ileostomy Liquid - Semi-formed Stool Dependent upon amount of bowel removed May skew F&E balance (K+ & Na+) Digestive enzymes in stool irritate skin DONT give laxatives Ileostomy lavage may be done [If needed to clear food blockage] May NOT REQUIRE appliance Ileal Reservoir/Kock Pouch [If continent] 2. Colostomy a. Ascending Must wear appliance Semi-liquid stool b. Transverse Wear appliance Semi-formed stool c. Loop Stoma Proximal End (Functioning stoma) Distal End (Drains mucous) Plastic rod used to keep loop out Usually temporary d. Double Barrel 2 stomas Similar to loop but bowel is surgically severed e. Sigmoid Formed stool Bowel can be regulated so appliance not needed May be irrigated

Stoma Assessment

1. Color: Same color as mucous membranes 2. Edema: Common after surgery 3. Bleeding: Slight bleeding common after surgery

Psychological Reaction to Ostomy

1. Disturbed body image 2. Anxiety r/t feared rejection 3. Ineffective Coping r/t ostomy care Nursing Care a. Empty pouches when they are about 1/3 to 1/2 full, standard precautions b. If needed, protect skin around ileostomy stoma c. Ostomies threaten body image. d. Fears of mutilation, shame, rejection are common e. Clients may feel powerless because they cannot fully control bodily functions f. Assist client to establish normal elimination routine. g. Report immediately if: i. Stoma oozes blood when touched

ii. Blood in pouch iii. Bleeding from stoma iv. Client reports back pain, chills, or fever h. Teach client i. Types of equipment & their use ii. How to irrigate colostomy iii. Prevention of complications iv. How to avoid constipation, diarrhea, excessive gas v. Vital to drink plenty of fluids VI. TOTAL PARENTERAL NUTRITION

Gastrointestinal System/MJTayco/2009 19

Conditions Requiring TPN

Condition Preop Need for Nutritional Support GI Problems Cause
Inadequate

S.E. of Oncology Therapy Alcoholosim, Chronic Depression, Eating Disorders Head & Neck Disorders/Surgery

intake preop Poor nutritional state Fistula Short-bowel syndrome Crohns Disease Ulcerative Colitis Maldgestion/Malabsorp tion Radiation, Chemotherapy Chronic Illness Psychiatric Disorders
Disease or Trauma

1. TPN (Amino Acid-Dextrose Formulas) 3 Liters of solution/24Hours 500 ml 10% Fat Emulsions (Intralipid) /6Hours 1 3x/week Fine bacterial filter used 2. TNA (Total Nutrient Admixture) (Amino Acid-Dextrose-Lipid (3-in-1) 1 Liter of solution/24Hours NO Bacterial filter used

Types of Solutions

1. Peripheral To supplement oral intake DONT administer Dextrose concentrations > 10% [Irritate vessel walls] Used for Less than 2 weeks 2. Central Subclavian vein

Methods of Administration

Types

i. PIC (Peripherally Inserted Catheters): Basilic/Cephalic vein SVC ii. Percutaneous Central Catheters: Subclavian vein iii. Triple Lumen Central Catheter Distal Lumen (16-gauge): Infuse/Draw blood samples Middle Lumen (18-gauge): TPN Infusion Proximal Lumen (18-gauge): Infuse/Draw blood; Administer meds iv. Single Lumen Catheter DONT administer meds [May be incompatible]/BT [RBCs coat lumen] Meds/Blood must be given Peripheral IV line NOT piggyback to TPN line 3. Atrial i. Right Atrial Catheters: Hickman/Biovac & Groshong ii. SQ Port: Huber Needle [To access port via skin]

Nursing Care

a. Initial Rate: 50ml/Hour & gradually (100 125 ml/Hour) [F&E permits] b. Infuse solution by pump at constant rate [To prevent abrupt change in rate] i. : Hyperosmolar State (Headache, Nausea, Fever, Chills, Malaise) ii. : Rebound Hypoglycemia (d/t delayed pancreatic reaction to change in insulin requirements) c. Carefully monitored for Signs of Complications

Gastrointestinal System/MJTayco/2009 20

d. e. f. g. h. i. j.

Nursing Considerations a. Maintain closed IV system with filter b. NO blood drawn or meds via TPN line c. Dry, sterile occlusive dressings applied to site PNEUMOTHORAX (Line a. TPN to be started only after Placement) Chest X-ray validates correct placement HYPEROSMOLAR COMA Monitor glucose level & S. Osmolality Monitor urine fractional for glucose & acetone REBOUND a. S/Sx: Weakness, faintness, HYPOGLYCEMIA diaphoresis, shakiness, confusion, tachycardia b. Gradually taper Change IV tubing & filter Q24Hours Keep solutions refrigerated until needed; Allow to warm to room temperature before use New solution unavailable: 10% Dextrose & H2O solution until available Monitor Daily: Weight, Glucose, Temp., I&O Monitor 3x/week: BUN, Electrolytes (Mg+ & Ca++) Once/week: PT, Liver function, S. Albumin Discontinuation i. Gradually tapered [To allow patient to adjust to levels of glucose] ii. After Discontinuation: Isotonic Glucose Soln. [To prevent rebound hypoglycemia]

Complication SEPSIS

VII. GASTRIC SURGERIES Purpose: When Peptic Ulcer does not respond to medical management, Gastric Cancer

Types:

1. Vagotomy Severing of part of vagus nerve innervating the stomach [Gastric Acid Secretion] 2. Antrectomy Removal of the antrum of stomach [Eliminate Gastric Phase of digestion] 3. Pyloroplasty Enlargement of pyloric sphincter with acceleration of gastric emptying 4. Gastroduodenostomy (Billroth I) Removal of lower portion of the stomach with anastomosis of the remaining portion of duodenum 5. Gastrojejunostomy (Billroth II) Removal of antrum & distal portion of the stomach & duodenum with anastomosis of remaining portion of the stomach to jejunum 6. Gastrectomy Removal of 60 80% of stomach 7. Esophagojejunostomy (Total Gastrectomy) Removal of the entire stomach with a loop jejunum anastomosed to the esophagus Dumping Syndrome Abrupt emptying of stomach contents into intestine Common complication of Gastric Surgery

Associated with:
1. Presence of Hyperosmolar chime in jejunum draws fluid by osmosis from ECF Bowel Plasma volume 2. Distension of bowel Intestinal Motility

Signs & Symptoms:

1. Weakness 2. Faintness 3. Palpitations

4. 5. 6. 7. 8. 9.

Diaphoresis Feeling of Fullness Nausea Diarrhea (occasional) Appear: 15 30 minutes after meals Lasts: 20 60 minutes

Gastrointestinal System/MJTayco/2009 21

a. Routine Pre-op Care b. Routine Post-op Care c. Adequate Function of NG Tube i. Measure drainage accurately [Determine necessity for F&E replacement] ii. Notify Physician if theres NO Drainage iii. Anticipate frank, red bleeding (12 24H) d. Adequate Pulmonary Ventilation i. Mid- or High Fowlers [Promote Chest Expansion] ii. Splint high upper abdominal incision before turning, coughing, & deep breathing e. Adequate Nutrition i. Clear liquids small amounts of Bland Food at frequent intervals [After removal of NG tube] ii. Monitor Wt. daily iii. Assess for Regurgitation iv. Eat, smaller amounts of foods at slower pace [If regurgitation is present] f. Health Teaching i. Gradually increasing food intake until able to tolerate 3 meals/day ii. Daily Monitoring of Wt. iii. Stress Measure iv. Report: Hematemesis Vomiting Diarrhea Pain Melena Weakness Feeling of Abdominal fullness/distension v. Methods of Controlling Sx assoc. with Dumping Syndrome AVOID Concentrated Sweets 6 small, dry meals/day Modified diet NO Fluids after meals but 2H after meals Recumbent for hour after meals VIII. BOWEL SURGERIES Varies depending on location & extent of lesion Purpose: Crohns Disease, Ulcerative Colitis, Intestinal Obstructions, Colon/Rectal CA

Nursing Care

1. Abdominoperineal Resection Distal Sigmoid Colon, Rectum, & Anus are removed via perineal incision & Permanent Colostomy is created Indication: Cancer of the Colon/Rectum 2. Ileostomy Opening of the Ileum onto the abdominal surface Indication: Ulcerative Colitis, Crohns Disease 3. Kocks Pouch (Continent Ileostomy) Intra-abdominal reservoir with nipple valve is formed from Distal Ileum Pouch acts as Reservoir for fecal material & is cleaned at regular intervals by insertion of catheter 4. Cecostomy Opening between the Cecum & Abdominal base temporarily diverts flow Indication: To Rest the Distal portion of colon after Surgery 5. Temporary Colostomy Located in Ascending or Transverse Colon Indication: To Rest bowel 6. Double-Barreled Colostomy

Types

Gastrointestinal System/MJTayco/2009 22

Colon is resected & both ends are brought through abdominal wall creating 2

stomas (Proximal & Distal) Indication: For an Obstruction or Tumor in Descending or Transverse Colon 7. Loop Colostomy Often a temporary procedure whereby a loop bowel is brought out above the skin surface & held in place by glass rod 1 Stoma but 2 Openings (Proximal & Distal) 8. Permanent Colostomy Single Stoma made when Distal portion of bowel is removed Sigmoid or Descending Colon 9. Resection with Anastomosis Diseased part is removed Remaining portions anastomosed Allowing Elimination through the Rectum

a. Routine Pre-op Care + i. Ensure adherence to dietary restrictions Clear liquids only on day before surgery Calorie, Residue diet 3 -5 days before surgery ii. Assist with bowel prep. Antibiotics 3 5 days pre-op [ bacteria in intestine] Enemas (possibly with added antibiotics) [Further cleanse the bowel] iii. Vit. C & K ( by bowel cleansing) [Prevent post-op complications] b. Routine Post-op Care + i. Promote elimination Assess signs of returning peristalsis Monitor characteristics of initial stools ii. Monitor & Maintain F&E c. Abdominoperineal Resection i. Reinforce & change perineal dressings PRN ii. Record type, amount, color of drainage iii. Irrigate with NSS or Hydrogen Peroxide iv. Warm Sitz baths 4times/day v. Cover wound with dry dressing d. Colostomy i. Prevent skin breakdown Cleanse skin around stoma with mild soap & H2O & pat dry Skin barrier [Protect skin around stoma] Assess skin regularly for irritation AVOID use of adhesives on irritated skin ii. Control odor, maintain pleasant environment Change pouch/seal PRN Empty/clean bag frequently & provide ventilation after Deodorizer in bag/room AVOID gas-producing foods iii. Promote adequate stomal drainage Assess stoma for color & intactness Expect mucoid/serosanguinous drainage (1st 24H) Liquid Assess for flatus [Return of intestinal function] Monitor for changing consistency of fecal drainage iv. Irrigate colostomy PRN Position client on toilet or in High-Fowlers (Bed rest) Fill irrigation bag with desired amount of H2O (500 1000 ml) Hang bag so the bottom is at shoulder height Remove air from tubing & lubricate the tip of catheter/cone Remove old pouch & clean skin & stoma with H2O Gently dilate stoma & insert the irrigation catheter/cone snugly Open tubing & allow fluid to enter bowel Remove catheter/cone & allow fecal contents to drain Observe & record amount & character of fecal return v. Promote adequate nutrition Assess return of peristalsis Advance DAT, add new foods gradually AVOID constipating foods

Nursing Care

Gastrointestinal System/MJTayco/2009 23

vi. Liquid: 2,500 ml/day vii. Encourage client to discuss feelings & concerns about surgery viii. Teach how to Recognize & Report Complications Changes in odor, consistency, & color of stools Bleeding from stoma Persistent constipation & diarrhea Changes in contour of stoma Persistent leakage around stoma Skin irritation despite treatment ix. Teach proper procedure for colostomy irrigation