GIT

1. Mouth
2. Pharynx
3. Esophagus
4. Stomach
5. Small intestine
6. Large intestine

A. Gastrointestinal Tract

1. Mouth

Mechanical and chemical digestion

1. Mouth

Digestion of CHO in the mouth (Partial digestion of CHO) because of the salivary amylase - No digestion of fats and protein

2. Pharynx

Acts as passageway of food from mouth down to the esophagus

2. Pharynx

No digestion occurs

3. Esophagus

Long tube; 25 cm long

3. Esophagus

Serves as passageway of food from the pharynx down to the stomach

3. Esophagus

• No digestion occurs
• Has mucus to allow easy passage of food

3. Esophagus

Two important structures: Upper Esophageal Sphincter and Lower Esophageal Sphincter

Lower Esophageal Sphincter

• Acts as a gate
• opens to allow entrance of food to the stomach, once food reaches stomach it closes (competently, it has to close); prevents reflux of acid/gastric contents

Barrett's Esophagus

Continuous reflux of acid, which irritates the esophageal lining, will lead to the condition kown as?

4. Stomach

Is divided into 3 main parts: Cardia, Fundus (Body), Pylorus

4. Stomach

J-shaped; Stores 2-4 liters; Food stays in for about 3-4 hours

4. Stomach

• Takes time for chyme to go into the small intestine
• Mechanical digestion and chemical digestion — Food is broken down into smaller pieces; Gastric acid is released to further break down food

4. Stomach

• Consists of several layers:

1. Mucosa
2. Muscularis Mucosa
3. Submucosa — Blood vessels can be found
4. Muscle layer
5. Subserosa
6. Serosa

Chief cells

__ — Pepsinogen → For digestion of proteins (CHON) - Protein is partially digested in the stomach

Lipase

__ is produced in a very minimal amount → For digestion of fats - Fats go slowly in the small intestine

Parietal cells

_ — Secretes Hydrochloric acid (1.5-3.5 pH) - Highly acidic to kill the bacteria that enters the GIT

Intrinsic factor

__ — Needed for absorption of vitamin B12

mucous cells; bicarbonate-rich mucus

Stomach has _ that produces __ → Neutralizes the acid; These are completely replaced at least every 6 days

5. Small intestine

Divided into 3 parts: Duodenum, Jejunum, Ileum

5. Small intestine

Site of final digestion and absorption of nutrients

5. Small intestine

produces its own intestinal juice — To aid in the digestive process

5. Small intestine

Bile from the gallbladder goes to _ for fat emulsification

5. Small intestine

Final digestive process

5. Small intestine

Pancreatic enzymes will go to _ (amylase, lipase, trypsin)

• Amylase — CHO
• Lipase — Fats
• Trypsin — CHON

Pancreatic enzymes will go to small intestine (amylase, lipase, trypsin):

villi and microvilli (Nutrients → villi and microvilli → hepatic portal vein → liver)

Absorption of nutrients through —

6. Large intestine

Divided into 4 parts: Cecum, Colon, Rectum, Anus

6. Large intestine

Parts of colon: Ascending, Transverse, Descending, Sigmoid

6. Large intestine

Site of water and electrolyte absorption

6. Large intestine

Undigested food will be formed into feces/stool — Formation of feces/stool; Elimination of feces/stool

6. Large intestine

Is lined with more mucus compared to the small intestine to promote movement of feces along the colon for easy elimination

Pancreas, liver, gallbladder

B. Accessory Organs

1. Liver

Produces bile for emulsification of fats

1. Liver

Largest internal organ of the body

1. Liver

• 1,200-1,500 g
• Lobule

• Hepatic portal vein — Nutrient-rich blood
• Hepatic artery — Oxygenated blood
• Hepatic vein — Deoxygenated blood

Blood vessels of the liver:

1. Glucose metabolism
2. CHON (Protein) metabolism
3. Fat metabolism
4. Storage
5. Detoxification
6. Ammonia → Urea
7. Phagocytosis: Kupffer cells
8. Blood reservoir: Between 200-400 ml of blood
9. Bilirubin excretion

→ Functions of the liver:

1. Glycogenesis — Glucose → Glycogen
2. Lipogenesis — CHO → Fats
3. Glycogenolysis — Glycogen → Glucose

→ Functions of the liver: - 1. Glucose metabolism

Synthesis of:

1. Plasma CHON: Albumin (Maintains osmotic pressure), Alpha and beta globulins (Antibodies)
2. Clotting factors: Fibrinogen, prothrombin
3. Gluconeogenesis — CHON → Glucose

→ Functions of the liver: - 2. CHON (Protein) metabolism

1. Metabolism of triglycerides to fatty acids
2. Bile synthesis: 600-1,200 ml yellow green in color
3. Functions:
   1. Excretion of bilirubin
   2. Emulsification of fats, cholesterol and fat-soluble vitamins
4. Bile
   1. Composed of water and electrolytes (Na, K, Ca, Chloride, Bicarbonate), lecithin, fatty acids, cholesterol, bilirubin, bile salts
   2. Enterohepatic circulation — Hepatocytes, bile, intestine

→ Functions of the liver: - 3. Fat metabolism

1. CHO, CHON, Fats
2. Fat-soluble vitamins (ADEK)
3. Water soluble vitamins
4. Minerals: Iron, copper, magnesium

→ Functions of the liver: - 4. Storage

1. Steroid hormones
2. Drugs

→ Functions of the liver: - 5. Detoxification

1. Ammonia comes from the breakdown of proteins
2. CHON → Amino acid → Further breakdown → Ammonia
3. Ammonia stays in the blood, may be deposited in the brain if it is not converted into urea; Urea is excreted through the urine
4. Ammonia in the brain → May lead to encephalopathy

→ Functions of the liver: - 6. Ammonia → Urea

1. Bilirubin comes from breakdown of RBC
2. RBC → Hemoglobin → Divided into Heme and Globin
   1. Heme → Divided into Iron and Bilirubin
   2. Bilirubin is unconjugated and insoluble; should be made conjugated and soluble to be excreted from the body
   3. Bilirubin is excreted through urine and stool

• Urine — Urobilin
• Stool — Stercobilin

1. Liver produces glucoronyl transferase to convert bilirubin to its soluble form
2. If bile cannot be excreted, mabalik siya kung diin sya ga halin → Yellowish skin/Jaundice

→ Functions of the liver: - 9. Bilirubin excretion

2. Gallbladder

Storage and concentration of bile

2. Gallbladder

The longer the bile stays in the , the more concentrated, easier for bile to form stones

1. Liver
2. Common hepatic duct
3. Cystic duct
4. Gallbladdet
5. Cystic duct
6. Common bile duct
7. Sphincter of oddi
8. Small intestine

Enterohepatic circulation

3. Pancreas

Endocrine function — Hormones

3. Pancreas

Exocrine function — Enzymes

Common bile duct

Common pathway of enzymes and bile

3. Pancreas

When the produces its enzymes, they are inactive — they are not ready for digestion of CHO, CHON, and fats

3. Pancreas

Soft, longitudinal, tapered, lobular gland

3. Pancreas

Secretes pancreatic enzymes (amylase, lipase, trypsin)

C. Process of Ingestion

Process of taking in food through the mouth

D. Process of Digestion

Mechanical and chemical break down of food into small organic fragments

E. Process of Elimination

Elimination of undigested food content and waste products

• Older than 65 years: Dentures or partial plates and bridges; Ill-fitting dentures cause eating problems and can lead to nutritional deficits.

• With advanced age: muscles for swallowing becomes weaker and less coordinated; food particles are retained in the cheek pouches or pharynx.

• The esophageal sphincter become less efficient at opening and closing, and risk for aspiration increases.

• Taste buds atrophy, causing inability to distinguish between flavors, particularly between salty and sweet.

• After age 70: parietal cells in the stomach decrease their secretion of hydrochloric acid, enzyme and intrinsic factor.

• The mucosa of the small intestine becomes less absorptive, and the large intestine may develop diminished motility.

II. Assessment of the Gastrointestinal System - A. Age-related changes 1. In the GIT

• Gallstone incidence is higher in older adults

• Secretion of lipase from the pancreas decreases, altering fat
  digestion, and may contribute to a depressed nutritional state
  in older adults

II. Assessment of the Gastrointestinal System - A. Age-related changes 2. In the Accessory Organs

• Age
• Gender
• Culture
• Occupation

B. Physical assessment - 1. Subjective Data
a. Demographic Data

• Previous GI disorders
• Abdominal surgery
• History of diabetes, CA of the digestive tract, peptic ulcer, gallbladder disease, hepatitis, alcoholism, intestinal polyps, obesity

B. Physical assessment - 1. Subjective Data
b. Personal and family history

• Conditions manifested may result from alterations in dietary intake and abosrption of nutrients
• Inquire about any special diet and food allergies
• Describe usual foods eaten daily and the time meals are taken
• Explore any changes that have occurred in eating habits as a result of illness
• Changes in taste and any difficulty (dysphagia) or pain with swallowing (odynophagia)
• Abdominal pain/discomfort accompanies eating, nausea, vomiting or dyspepsia
• Unintentional weight loss
• Alcohol and caffeine consumption

B. Physical assessment - 1. Subjective Data c. Diet history

Ability to obtain food, medications, and medical care

B. Physical assessment - 1. Subjective Data d. Socioeconomic status

• Chronologic account of the current problem, symptoms, and treatments taken
• Explore characteristics associated with each symptom
• Types of pain: Burning, gnawing, stabbing
• Location of pain: Point involved site

B. Physical assessment - 1. Subjective Data e. Current health problems

• Equipment: Gloves, penlight, tongue depressor

→ Inspect:

• Lips — Color, moisture, cracking, lesion
• Inner surfaces of the lips and oral mucosa
• Tongue — Color, coating, ulcers, and variations in size and shape
• Teeth — Evidence of dental caries and note the absence of teeth
• Gums — Pink, moist, and smooth
• Describe moisture, color, and lesion

→ Note unpleasant odors

• Fetor oris/Halitosis — Bad breath
• Acetone breath — Common in patients with DKA
• Ammonia/Uremic fetor — Common in patients with CKD

B. Physical assessment - 2. Objective data - a. Mouth

• Use tongue depressor to depress the tongue and examine the pharynx; instruct to say "ah" — Uvula rises at the center
• Pinkish in color

→ Palpate:

• U-shape under the tongue for nodules

B. Physical assessment - 2. Objective data - b. Pharynx

→ Preparation:

1. Empty the bladder.
2. Lie in a supine position head raised slightly with knees bent or slightly flexed, keeping arms at the sides to prevent inadvertent tensing of the abdominal muscle. (Dorsal recumbent)
   1. RLQ
   2. RUQ
   3. LUQ
   4. LLQ
      → Inspect:
3. Color, texture, scars, striae, shape, rashes, lesions, and dilated blood vessel symmetry, bulging, muscular position and condition of umbilicus, and movements.
4. Describe the contour:
   1. Flat
   2. Convex (Rounded)
   3. Concave (Sunken)
   4. Protuberant or distended

B. Physical assessment - 2. Objective data - c. Abdomen (IAPP)

Fecal occult blood test (FOBT)

Analysis of stool for blood (for parasites, blood, etc.)

1. Explain the procedure.
2. Advise patient to red meat, iron, and high fiber for 1-3 days.
3. Document the administration of aspirin, vitamin C, and anti-inflammatory drugs.

1. Fecal analysis (Stool examination) → Nursing care:

2. Serum Bilirubin

• To detect abnormal bilirubin metabolism
• Normal values:
  • Total: 0.3 - 1.9mg/dl
  • Direct: 0 - 0.3 mg/dl

3. Alanine aminotransferase (ALT)

• An enzyme used to detect liver disease
• Normal value: 1 - 45 International units/L

4. Aspartate aminotransferase (AST)

• An enzyme found in heart, liver, and muscle tissue; to detect acute hepatitis or biliary destruction
• Normal value: 1 - 36 units/L

5. Alkaline phosphatase (ALP)

• Enzyme found in bone, liver and placenta; to detect liver tumor in conjunction with other liver findings; rises when there is destruction of the biliary tree
• Normal value: 35 - 150 units/L

6. Albumin

• To detect altered CHON metabolism
• Normal value: 3.5 - 5.5 g/dL

7. Prothrombin (PT)

• Reduced in patients with liver disease, causing a prolonged clotting time
• Normal value: 12.0 - 14.0 sec

8. Partial thromboplastin time (PTT)

• To detect deficiencies of stage II clotting mechanisms; prolonged in liver disease
• Normal value: 60 - 70 sec

9. Activated PTT (APTT)

• Decreased in liver failure
• Normal value: 20 - 35 sec

10. Helicobacter pylori antibody test

• To detect antibodies to H. pylori bacterium in the stomach; H pylori is a risk factor for gastric and duodenal ulcers, chronic gastritis, or ulcerative esophagitis
• Normal: none present

11. Esophageal Ph Monitoring/24-hour pH testing

• Probe is placed 5 cm above LES and pH is measured for 24 hours
• pH less than 4 above the LES = GERD

• nstruct patient not to use any antacids, chewing gum, lozenges or hard candy during the study
• For throat discomfort: ice chips or dyclonine hydrochloride (Cepacol) spray
• To prevent reflux: avoid large meals, caffeine, alcohol, and lying in supine position after meals.

11. Esophageal Ph Monitoring/24-hour pH testing → Nursing Care

1. Upper GI Series (UGI) or Barium Swallow

To locate obstruction, ulceration, or growths in the esophagus, stomach and duodenum

1. Light supper — Soup, toast, jello, or tea night before the procedure
2. Advise the client to be on NPO and avoid smoking 8-12 hours before the exam.
3. Client will drink 16-20 ounces of a chalky liquid (barium sulfate or meglumine diatrizoate (Gastrografin) before the exam.
4. Following the exam, ensure the client eliminates the barium by giving laxatives and forcing fluids as appropriate.
5. Stool may be white up to 3 days after the test.
6. Observe for barium impaction: Distended abdomen, constipation

1. Upper GI Series (UGI) or Barium Swallow → Nursing care:

2. Barium enema (BE)

To locate tumors, obstruction, and ulceration

1. Advise client to be on NPO 8 hours before the test.
2. Give ordered laxative and enema; bowel must be clear of stool.

2. Barium enema (BE) → Nursing care:

3. Computed Tomography Scan (CT)

To visualize soft tissue and density changes when sonography is inconclusive; to detect tumors, abscesses, trauma, cysts, inflammation, and bleeding

1. Advise client to be on NPO for 4 hours when oral contrast is to be used
2. Secure consent
3. Assess for allergy to iodine or shellfish

• Explain the following:

1. Position will be supine on special narrow table and that the body will be in the circular opening of the scanner.
2. A strap will be placed over the waist to secure him on the table.
3. The test takes about 30 mins.
4. An IV contrast agent that causes a transitory warm feeling may be given to enhance images.
5. Patient will be asked to hold his breath at certain points in the test.
6. The machine uses narrow x-ray beams

3. Computed Tomography Scan (CT) → Nursing care:

4. MRI

With or without contrast — to evaluate abnormalities in the liver or other abdominal structures

1. Assess for metal implants (wil not do the exam if present)
2. Remove all metal objects including dental bridges

4. MRI → Nursing care:

5. Ultrasound Imaging Ultrasonography

To obtain images of soft tissue that indicate density changes; to diagnose gallstones, tumor, cysts, absecesses, etc.

1. Advise client to remain NPO for 8-12 hours prior to the test
2. Remove the KY Jelly

5. Ultrasound Imaging Ultrasonography → Nursing care:

1. Upper GI Endoscopy/Esophagogastroduodenoscopy

To visualize the esophagus, stomach, and duodenum with a lighted tube to detect tumor, ulceration, site of bleeding or obstruction

→ Nursing care (Preparation):

1. Advise client to remain NPO for 8 hours prior to the test
2. Secure consent

→ After the test

1. Side-lying position
2. Remain on NPO after he test until gag reflex returns

• Clear liquid diet to soft diet to DAT

1. NSS gargle, throat lozenges
2. Vital signs q15-30 minutes as ordered
3. Watch for signs of perforation: Rising temperature, pain, changes in vital signs
4. Assess for bleeding, neck or throat pain and dyspnea
5. Avoid driving if given sedatives

1. Upper GI Endoscopy/Esophagogastroduodenoscopy → Nursing care:

2. Lower GI endoscopy

To directly view the lining of the colon with a flexible endoscope

1. Secure consent
2. Clear liquid 1 - 3 days before the test
3. NPO 8 hours before the test
4. Bowel preparation as ordered
5. After the test observe for rectal bleeding and signs of perforation

2. Lower GI endoscopy → Nursing Care:

3. Endoscopic Retrograde Cholangiopancreatography (ERCP)

To directly visualize gastrointestinal structures, and to retrieve gallstones from the distal common bile duct, dilate structures, and biopsy tumors

1. Advise client to be on NPO for 8 hours before the test.
2. Following the test, assess vital signs and gag reflex, and monitor for complications (pancreatitis is the most common).

3. Endoscopic Retrograde Cholangiopancreatography (ERCP) → Nursing care:

4. Liver biopsy

To remove a tissue sample for microscopic examination and diagnosis of various liver disorders

1. Secure consent
2. NPO 4 - 8 hours prior to the test
3. Place patient in supine or left lateral position
4. Procedure may take 15 mins
5. Assess for allergy to local anesthetics
6. Empty the bladder prior to the procedure
7. Check coagulation studies for abnormalities
8. After biopsy, place a small dressing over puncture site; position patient on right side with support to provide pressure over biopsy site for 1 -2 hours; observe for bleedin
9. Monitor vital signs q 15 mins for 1 hour; then q 30 mins for 4 hours; then q 4 for 24 hours
10. Assess for tenderness at biopsy site
11. Observe for respiratory problems
12. Instruct patient to avoid coughing or straining, that might increase intra-abdominal pressure
13. Refrain from heavy lifting or strenuous activities for 1 - 2 weeks

4. Liver biopsy → Nursing care:

5. Esophageal pH monitoring

Probe is placed 5 cm above LES and pH is measured for 24 hours