Gastrointestinal Function



Gastrointestinal Function


Linda A. Stamm, APN, BC, Laurel A. Wiersema-Bryant, ANP, BC and Cassandra Ward, ANP-C




The gastrointestinal (GI) system, including the accessory organs of digestion, functions in the ingestion, digestion, and absorption of nutrients essential for life and growth, as well as in the excretion of solid wastes from the body. GI system–related symptoms and complaints are common with advancing age, and the nurse is often the first health care provider to identify and acknowledge them. Therefore knowledge of normal and age-related changes in the GI system is essential in providing appropriate nursing care.



Age-Related Changes in Structure and Function


Although many health-related complaints from older adults pertain to the GI system, these complaints are rarely responsible for death. Older individuals are usually very aware of alterations in GI function, and many of these changes can be ameliorated through appropriate self-care practices. Some changes in the GI tract are due to normal aging; however, multiple factors such as polypharmacy, stress, poor nutrition, multiple comorbidities and poor, hygiene may all contribute to an alteration in GI function. Just as often, misinformation about GI changes can lead to more complex problems because of failure to seek health care or engage in appropriate preventive and treatment measures. The nurse has the responsibility for teaching prevention and self-management strategies to these clients.


Many of the systemic changes in the functions of digestion and absorption of nutrients result from changes in older clients’ cardiovascular and neurologic systems rather than their GI systems. For example, atherosclerosis and other cardiovascular problems may cause a decrease in mesenteric blood flow, leading to a decrease in absorption in the small intestine. Additionally, the central and peripheral nervous systems affect the motility of the entire GI system, and any change may alter peristalsis, thereby reducing or increasing transit time. A decrease in mobility, often seen in the older adult, can also affect normal GI function.



Oral Cavity and Pharynx


Changes in the oral cavity have an effect not only on an older person’s well being, comfort, and health, but also on overall nutrition and digestion. The most obvious change in the mouth is the loss of teeth. One fourth of adults who are 65 or older are edentulous (without teeth). More than 7000 people, mainly elderly, die each year from pharyngeal and oral cancers. Periodontal gum disease caused by bacterial infection under the gum destroys both bone and gum. Teeth become loose, chewing becomes more difficult, and often the teeth must be extracted (Centers for Disease Control and Prevention [CDC], 2009a).


Taste buds may atrophy with age, resulting in an inability to discriminate among flavors, especially salty and sweet. This may contribute to decreased enjoyment of food, resulting in poor eating habits and nutritional deficiencies. Medications such as diuretics, anticholinergics, certain antidepressants and antipsychotics reduce saliva production and oral lubrication, which normally function to protect the oral tissues (Lewis, Heitkemper, Dirksen, & O’Brien, 2007).


Healthy People 2010 reflects on the importance of oral health as an integral component of healthy life. Poor oral health and disease conditions have a significant impact on the older adult’s feelings of self-esteem and depression. One of the goals of Healthy People 2010 is to improve access to preventive oral care and early intervention services for older adults (US Department of Health and Human Services, 2000).




Stomach


Age-related changes in the stomach include degeneration of the gastric mucosa, decreased secretion of gastric acids and digestive enzymes, and decreased motility (Lewis et al, 2007). The stomach of an older adult is not able to accommodate large amounts of food because of decreased elasticity. The ability to empty gastric contents as quickly is also diminished in the older adult, which quickly results in a feeling of fullness or early satiation.


By the age of 60, gastric secretions decrease to 70% to 80% of those of the average adult. A decrease in pepsin may hinder protein digestion, whereas a decrease in hydrochloric acid and intrinsic factor may lead to malabsorption of iron, vitamin B12, calcium, and folic acid. This, combined with atrophy of the mucosa and a decrease in gastric secretions, increases the incidence of pernicious anemia, peptic ulcer disease (PUD), and stomach cancer.





Gallbladder


The gallbladder and bile ducts are unaffected by aging. However, the incidence of gallstones does increase with age. Bile may become more lithogenic with advancing age, possibly because of an increase in biliary cholesterol related to diet and hormonal changes that affect cholesterol metabolism. The bile salt pool also decreases as a result of a decrease in bile salt synthesis. These predispositions for stone development, along with a tendency for dehydration in older adults, explain the increased incidence of cholelithiasis and cholecystitis in older adults. The complications of cholelithiasis in older adults include empyema, perforation, and choledocholithiasis (calculi in the common bile duct). These complications are often seen in persons older than age 65 and those with diabetes (Lewis et al, 2007).




Liver


The liver is a sturdy organ and retains most of its functions throughout the life span. Although the liver size decreases after age 50, liver function tests may remain within normal limits. A decline in cardiac output associated with aging contributes to a decrease in hepatic blood flow. As hepatic blood flow slows, drug metabolism is reduced, which leaves the aging liver more susceptible to drugs and toxins. Elderly persons have a decreased ability to compensate for infectious, immunologic, and metabolic disorders (Lewis et al, 2007). Some evidence suggests that normal aging may adversely affect liver tissue regeneration. The mechanism of this effect is not fully known, but it may be a result of a generalized slowing of repair or an inadequate response to regeneration of liver tissue.



Prevention


Although some changes in the GI system are associated with aging, there are strategies for both primary and secondary prevention of problems arising from these changes (Tables 26–1, 26–2 and Box 26–1). Nurses caring for older clients should include instruction regarding these strategies.




TABLE 26–1


AMERICAN CANCER SOCIETY GUIDELINES ON SCREENING AND SURVEILLANCE FOR THE EARLY DETECTION OF COLORECTAL ADENOMAS AND CANCER—AVERAGE-RISK WOMEN AND MEN AGES 50 OR OLDER




























TEST INTERVAL (BEGINNING AT AGE 50) COMMENT
Fecal occult blood test (FOBT) and flexible sigmoidoscopy FOBT annually and flexible sigmoidoscopy every 5 years Flexible sigmoidoscopy together with FOBT is preferred compared with FOBT or flexible sigmoidoscopy alone. All positive test results should be followed up with colonoscopy.
Flexible sigmoidoscopy Every 5 years All positive test results should be followed up with colonoscopy.
FOBT Annually The recommended take-home multiple sample method should be used. All positive test results should be followed up with colonoscopy.
Colonoscopy Every 10 years Colonoscopy provides an opportunity to visualize, sample and/or remove significant lesions.
Double contrast barium enema (DCBE) Every 5 years All positive test results should be followed up with colonoscopy.

If colonoscopy is unavailable, not feasible, or not desired by the patient, DCBE alone or the combination of flexible sigmoidoscopy and DCBE are acceptable alternatives. Adding flexible sigmoidoscopy to DCBE may provide a more comprehensive diagnostic evaluation than DCBE alone in finding significant lesions. A supplementary DCBE may be needed if a colonoscopic examination fails to reach the cecum, and a supplementary colonoscopy may be needed if a DCBE identifies a possible lesion or does not adequately visualize the entire colorectum.


There is no justification for repeating FOBT in response to an initial positive finding.


Data from Smith R, Cokkinides V, Brawley O: Cancer screening in the United States, 2009: a review of current American Cancer Society Guidelines and issues in cancer screening. CA Cancer J Clin 59(1):27–41, 2009.



TABLE 26–2


AMERICAN CANCER SOCIETY GUIDELINES ON SCREENING AND SURVEILLANCE FOR THE EARLY DETECTION OF COLORECTAL ADENOMAS AND CANCER—WOMEN AND MEN AT INCREASED RISK OR AT HIGH RISK























































RISK CATEGORY AGE TO BEGIN RECOMMENDATION COMMENT
Increased Risk      
People with a single, small (<1 cm) adenoma 3–6 years after the initial polypectomy Colonoscopy If the examination is normal, the patient can thereafter be screened as per average risk guidelines.
People with a large (1 cm +) adenoma, multiple adenomas, or adenomas with high-grade dysplasia or villous change. Within 3 years after the initial polypectomy Colonoscopy If normal, repeat examination in 3 years; If normal then, the patient can thereafter be screened as per average risk guidelines.
Personal history of curative-intent resection of colorectal cancer Within 1 year after cancer resection Colonoscopy If normal, repeat examination in 3 years; If normal then, repeat examination every 5 years.
Either colorectal cancer or adenomatous polyps, in any first-degree relative before age 60 or in two or more first-degree relatives at any age (if not a hereditary syndrome) Age 40, or 10 years before the youngest case in the immediate family Colonoscopy Every 5–10 years. Colorectal cancer in relatives more distant than first-degree does not increase risk substantially above the average risk group.
High Risk      
Family history of familial adenomatous polyposis (FAP) Puberty Early surveillance with endoscopy and counseling to consider genetic testing If the genetic test is positive, colectomy is indicated. These patients are best referred to a center with experience in the management of FAP.
Family history of hereditary nonpolyposis colon cancer (HNPCC) Age 21 Colonoscopy and counseling to consider genetic testing If the genetic test is positive or if the patient has not had genetic testing, every 1–2 years until age 40, then annually. These patients are best referred to a center with experience in the management of HNPCC.
Inflammatory bowel disease, chronic ulcerative colitis, Crohn’s disease Cancer risk begins to be significant 8 years after the onset of pancolitis, or 12–15 years after the onset of left-sided colitis Colonoscopy with biopsies for dysplasia Every 1–2 years. These patients are best referred to a center with experience in the surveillance and management of inflammatory bowel disease.


image


If colonoscopy is unavailable, not feasible, or not desired by the patient, double contrast barium enema (DCBE) alone or the combination of flexible sigmoidoscopy and DCBE are acceptable alternatives. Adding flexible sigmoidoscopy to DCBE may provide a more comprehensive diagnostic evaluation than DCBE alone in finding significant lesions. A supplementary DCBE may be needed if a colonoscopic examination fails to reach the cecum, and a supplementary colonoscopy may be needed if a DCBE identifies a possible lesion or does not adequately visualize the entire colorectum.


From Smith R, Cokkinides V, Brawley O: Cancer screening in the United States, 2009: a review of current American Cancer Society Guidelines and issues in cancer screening. CA Cancer J Clin 59(1):27–41, 2009.



Common Gastrointestinal Symptoms


No clear-cut GI diseases can be attributed directly to the aging process. However, many conditions show a higher incidence in older adults and have a greater effect on their physical and social well-being. These complaints can be related to normal physiologic changes associated with aging but must be distinguished from pathologic problems that increase in frequency with aging.


Older adults may complain of symptoms related to the GI tract that have not been related to a specific diagnosis. Any symptom reported by an older client needs to be thoroughly assessed by the nurse. Following are a few of the common GI symptoms experienced by older adults; the sections include information on their definitions, assessment, nursing interventions, and self-care measures. (For more on nursing assessment as it relates to various cultures, see Chapter 4)



Nausea and Vomiting


Vomiting is controlled through a central vomiting center in the medulla. This center is close to the pain and respiratory centers; it is also near the centers that control vestibular and vasomotor function. Occasionally stimuli from one center spill over to another, and symptoms may become mixed. No distinct nausea center exists; however, the symptom of nausea may result from early stimulation of the vomiting center (Fig. 26–1).



Nausea may be difficult for clients to describe; many use the phrase “I feel sick” to convey the symptom of nausea. It is important to keep in mind that although nausea usually precedes vomiting, it may also be a freestanding symptom. In general, nausea in the absence of vomiting is of central, rather than peripheral, origin (i.e., the symptom is initiated centrally in the brain rather than peripherally in the GI tract). Central nausea is usually a response to a metabolic disorder.


It is important to obtain a detailed description of events surrounding a complaint of nausea and vomiting. Data should be elicited about precipitating factors (e.g., the relationship of nausea and vomiting to food intake, medications, and activity). The client should be questioned about the presence of nausea and vomiting, as well as diarrhea or constipation. It is important to obtain information about the amount and characteristics of the emesis and whether the vomitus contained food particles, bile, or blood (bright red or the color of coffee grounds). Other symptoms such as a fever, sweating, pallor, dizziness, and pain should be determined. Because older adults are at particular risk for dehydration and electrolyte imbalances, it is essential to establish the frequency and amount of emesis and to examine clients for signs and symptoms of fluid and electrolyte imbalances.


Nursing interventions include many self-help measures, including dietary changes such as drinking clear liquids, progressing from eating bland foods to solid foods, and small frequent feedings. If vomiting occurs, fluid replacement should be a priority. Sips of fluids every 15 minutes until more can be tolerated may decrease episodes of dehydration. Older adults are at high risk for aspiration, and they should be placed in a semi-Fowler’s or side-lying position when drinking liquids. It is important that older adults be made aware of the signs and symptoms of dehydration and electrolyte imbalances, as well as when to seek medical care. Any episodes of prolonged nausea or vomiting require careful evaluation by a health care provider. In addition, it should be made clear that pharmacologic therapy used to treat nausea and vomiting can cause sedation, confusion, and delirium in the older adult.



Anorexia


Anorexia as a symptom should not be confused with anorexia nervosa, which is an eating disorder of psychiatric significance. The term anorexia literally means “lack of appetite.” Hunger and appetite are not synonymous; hunger is related to the physiologic need for food. It is important for the nurse to ascertain whether the decreased food intake is truly because of a loss of appetite. Once that is determined, the nurse must ask questions regarding other symptoms, including weight loss, nausea, vomiting, abdominal pain, diarrhea, and constipation. In addition, psychosocial factors such as stress, grief, pain, and concomitant illnesses may also need to be assessed. Older adults are often faced with limited financial resources. This may result in them purchasing less fresh fruits and vegetables and may limit their overall ability to purchase enough food (Lewis et al, 2007).


Nursing interventions for older clients with anorexia include monitoring of intake, output, and weight. It is important to acknowledge a client’s symptoms and provide gentle encouragement for him or her to eat for nutritional purposes. Small, frequent feedings may be helpful. Encouraging older clients to seek medical attention for anorexia is also important because clients may not be aware of the problem.



Abdominal Pain


The symptom of abdominal pain is often difficult to fully assess. With older adults, it can be even more difficult, even for a skilled clinician. The assessment of pain can be made easier by thinking in terms of the three pathways for pain impulses. The first type are the visceral pain pathways, which are activated by receptors in the wall of the abdominal viscera and develop from stretching or distending the abdominal wall or from inflammation. This pain is often diffuse, is poorly localized, and has a gnawing, burning, or cramping quality. The second type are somatic or parietal pathways, which are activated by receptors in the parietal peritoneum and other supporting tissues. This type of pain is usually sharp, more intense, constant, and better localized than visceral pain. The third type are referral pathways, which account for referred pain (i.e., pain felt at a different site than the source of the pain but sharing the same dermatome). This pain is usually sharp and well localized; it may resemble somatic pain (Fig. 26–2).



In assessing any type of pain, the nurse should elicit information about its duration, location, mode of onset (sudden or gradual), intensity, quality, rhythm, relationship to food, alleviating and aggravating factors, and radiation (e.g., back, neck, or groin), as well as the older client’s ability to pass stool and gas. Elderly persons may complain of vague symptoms and wait much longer than their younger counterparts to seek medical care. The elderly are also less likely to exhibit leukocytosis (an increased white blood cell count), fevers, rebound tenderness, or local rigidity (Tazkarji, 2008).


Nursing interventions include measures to increase comfort and pain relief. Again, the nurse should encourage older clients to see their health care provider for a complete evaluation of the abdominal pain. Abdominal pain that is severe is often known as an acute abdomen. Nursing procedures commonly done for an acute abdomen include (1) starting intravenous fluids as ordered, (2) placing a nasogastric tube for decompression of the stomach, (3) monitoring and recording vital signs and reporting abnormal findings, (4) monitoring intake and output frequently and recording accurate amounts hourly, and (5) completing an assessment on the onset of pain, presence of vomiting or diarrhea, presence of fever, and an accurate medical and surgical history.



Gas


Complaints come in the form of belching, bloating, fullness, and flatus. About 99% of the gas present in the GI tract of adults comprises five gases: nitrogen, oxygen, hydrogen, carbon dioxide, and methane. The percentage of each individual gas depends on the source; these sources include swallowing, diffusion of gas from the bloodstream to the intestinal lumen, and processing of food. All these gases are odorless; the unpleasant odor associated with flatus is probably a result of hydrogen sulfide that is metabolized from sulfur-containing foods. A frequency of 7 to 20 gas passages a day is considered normal. Intestinal gas is frequently accompanied by intense abdominal pain, which may be relieved by repositioning or walking.


Although belching primarily comes from the unconscious swallowing of air, it is important to assess clients for other symptoms suggestive of gastritis or PUD. Many complaints of bloating and fullness are related to a motility disorder or malabsorption, but in older adults the complaints must be taken more seriously. Further assessment is required, such as questioning about changes in bowel function, pain, and other GI tract symptoms.


Although the expulsion of flatus is a normal event, excessive flatus may have several causes. Some clients form more gas within the gut, some swallow more air, and others may have excessive flatus because of the nature of the foods consumed. Common culprits include beans, cabbage, legumes, raisins, and artificial sweeteners. In addition, clients who are lactose intolerant may produce more gas. Careful questioning may reveal one or a combination of these causes.


Nursing interventions focus on client education about the cause and nature of intestinal gas. The keys to treatment are changes in dietary factors (e.g., focusing on eating more slowly and avoiding gas-producing foods) and a routine exercise plan.



Diarrhea


Diarrhea is an increase in the frequency of stools, but many definitions also include a change in consistency (e.g., watery stools). Diarrhea may be due to increased bowel motility or interference in the normal absorption of water and nutrients in the bowel. When an older client complains of diarrhea, it is important to ascertain exactly what is meant. In addition, the description of the diarrhea may be useless unless a client’s normal bowel habits are known.


The nurse should ask about precipitating events (e.g., travel out of the country or eating at a restaurant), timing (intermittent or continuous), associated factors (fever, weight loss, abdominal pain, vomiting, dietary or medication changes, and any systemic diseases), characteristics of the diarrhea (frequency, consistency, volume, foul smell, presence of mucus or blood, incontinence, awakening from sleep [e.g., nocturnal diarrhea usually points to an organic cause rather than a functional or infectious cause]), and whether the onset was sudden. All these questions help assess the diarrhea further to aid in determining the cause.


Nursing care focuses on maintaining adequate fluid and electrolyte balance, assessing for complications, and providing emotional support as necessary. Usual water loss in stools is 150 mL/day; severe diarrhea can account for up to 5 to 10 L of water loss daily. Therefore, assessing for signs and symptoms of dehydration and volume depletion in older clients is important. Clients and their families need to learn to report complications such as increased thirst, weakness, dizziness, palpitations, and fatigue. If fluid and electrolyte imbalances occur, either oral or parenteral treatment may be required because diarrhea in older adults can be life threatening. Nursing interventions should also be aimed at identifying and correcting the cause. Administration of antibiotics may be necessary for infectious diarrhea. Depending on the causative factor, antispasmodic and antidiarrheal medications may also be used. Education of clients and their families should include instruction on dietary changes: older clients with chronic diarrhea should avoid gas-forming foods, vegetables, spices, and milk products, and clients with acute diarrhea should consume bland foods, such as the BRAT (bananas, rice, applesauce, toast) diet and clear liquids.



Constipation


Constipation is a common problem among the elderly secondary to physiologic changes and is often a complication of polypharmacy. Among those older than 65, women are more often affected than men. Constipation is often defined according to the patient’s perception of abnormal bowel function (Berman, Brooks, & Silver, 2007). However, normal bowel patterns differ greatly among individuals. For example, a client may have the misperception that one bowel movement a day is necessary for good health.


Common causes of constipation in the elderly include diet (decreased fiber intake), mechanical obstruction (fecal impaction and cancer), medication side effects (aluminum- and calcium-based antacids, iron preparations, anticholinergics, narcotics, antidepressants, antipsychotics, and overuse of laxatives), multiple comorbidities, and mobility and functional issues (Ginsberg, Phillips, Wallace, & Josephson, 2007). Perhaps the most widespread cause of constipation in older adults is diet. It is usually a lack of certain foods, rather than the addition of certain foods, that leads to the problem. For example, many foods, such as fresh fruits and vegetables, contain natural laxatives, although older adults may have difficulty eating these foods because of dental problems. A second dietary cause of constipation is the lack of fiber or bulk and a decrease in fluid intake. In general, unrefined foods have more fiber than the refined foods that are popular in American society.


It is important to keep in mind that constipation can be a result of overuse or improper use of laxatives because of excessive concern about the frequency of bowel movements. In this instance, the nurse can reinforce with a client and his or her family that as long as the consistency is normal and the bowel movements occur at regular intervals, there is no reason to take laxatives.


Limitations on mobility can greatly affect the ability of an elderly person to self-feed and physically reach the toilet. They may feel awkward depending on others for these functions. Subsequently, they may ignore the urge to defecate rather than ask for help to get to the toilet. They may also decrease fluid intake in an effort to prevent urinary incontinence. These factors may greatly influence regular bowel patterns (Lewis et al, 2007).


Constipation is treated through dietary measures such as increasing fluid intake and increasing fiber, combined with light exercise and development of a regular toileting routine that includes responding to the urge to defecate. In teaching older adults about dietary changes, the nurse can instruct them that fiber need not be a “medicine;” it can be a “food.”


Multiple medications are available to treat constipation, and many of them are available over the counter. Laxatives are defined as drugs used to facilitate or stimulate the passage of feces and are classified as bulking agents (bran, psyllium), surfactants (stool softeners), emollients (mineral oil), contact stimulants (cascara, castor oil, bisacodyl), saline cathartics (magnesium hydroxide [Milk of Magnesia], citrate, sodium or potassium phosphate), and osmotic agents (lactulose, sorbitol). Laxatives may also be categorized by speed of action: group I drugs (castor oil, saline laxatives in high doses) act in 2 to 6 hours and produce watery stool; group II drugs (other contact stimulants, low-dose saline laxatives) act in 6 to 12 hours and produce a semi formed stool; and group III medications (bulking agents, surfactants, lactulose) produce soft stools in 1 to 3 days.


In addition to oral laxatives, several rectal agents are available. Enemas provide immediate relief but should be limited in their use for long-term treatment. Soapsud enemas should never be used because they lead to mucosal irritation. Small-volume enemas such as Fleets are the easiest to use. Rectal suppositories (bisacodyl, glycerin) may also be used, but they must be retained for 20 to 30 minutes for optimum results, and so may be more difficult for older clients to use.



Fecal Incontinence


Fecal incontinence, the involuntary passing of stool, may be acute or chronic, and it demands evaluation. For older adults the loss of bowel control is devastating and may significantly alter their quality of life. Fecal incontinence may be a result of colorectal lesions (perianal disease, proctitis, and tumors), neurologic problems (dementia, stroke, spinal cord lesions), laxative abuse, unrecognized lactose intolerance, diabetic neuropathy, poor dietary habits, or immobility (Kane, Ouslander, Abrass, & Resnick, 2009).



Nursing interventions focus on education concerning the prevention and treatment of incontinence in older adults. Examining the cause of the incontinence is important for the nurse, client, and family. Laxative abuse is completely preventable and treatable simply with education and reassurance to the client that one or two bowel movements a day are not necessary to be “regular.”


Regardless of the cause, a program of bowel control (see Client/Family Teaching Box) can usually help an elderly client who is aware of and distressed by incontinence. It is important to reassure older clients that control and retraining are achievable because many older adults believe that fecal incontinence is the first step on the road to permanent institutionalization. Other nursing interventions include methods to deal with the embarrassment of the incontinence, ways to decrease fecal odor, use of adult diapers, and skin care.



Common Diseases of the Gastrointestinal Tract


The following is an overview of common GI disorders seen in older clients, including the related nursing care. Table 26–3 provides an explanation of the diagnostic tests used in this section.



TABLE 26–3


DIAGNOSTIC STUDIES































































































































































GASTROINTESTINAL SYSTEM
STUDY DESCRIPTION AND PURPOSE NURSING RESPONSIBILITY
Radiology    
Upper gastrointestinal (GI) or barium swallow X-ray study with fluoroscopy with contrast medium. Study is used to diagnose structural abnormalities of the esophagus, stomach, and duodenum. Explain procedure to patient, the need to drink contrast medium, and the need to assume various positions on x-ray table. Keep patient NPO for 8–12 hr before procedure. Tell patient to avoid smoking after midnight the night before the study. After x-ray, take measures to prevent contrast medium impaction (fluids, laxatives). Tell patient that stool may be white up to 72 hr after test.
Small bowel series Contrast medium is ingested and films taken every 30 min until medium reaches terminal ileum. Same as for upper GI.
Lower GI or barium enema Fluoroscopic x-ray examination of colon using contrast medium, which is administered rectally (enema). Double-contrast or air-contrast barium enema is test of choice. Air is infused after thick barium flows through the transverse colon.
Ultrasound Noninvasive procedure uses high-frequency sound waves (ultrasound waves), which are passed into body structures and recorded as they are reflected (bounded). A conductive gel (lubricant jelly) is applied to the skin and a transducer is placed on the area.  

Study detects abdominal masses (tumors and cysts) and is also used to assess ascites. Instruct patient to be NPO 8–12 hr before ultrasound. Air or gas can reduce quality of images. Food intake can cause gallbladder contraction, resulting in suboptimal study.

Study detects subphrenic abscesses, cysts, tumors, and cirrhosis and visualizes biliary ducts. Same as abdominal ultrasound.

Study detects gallstones. Same as abdominal ultrasound.

Study detects and stages esophageal tumors. Fine-needle aspiration can validate cancer or dysplasia. Same as upper GI endoscopy.
Computed tomography (CT) Noninvasive radiologic examination combines special x-ray machine used for CT that allows for exposures at different depths. Study detects biliary tract, liver, and pancreatic disorders. Use of contrast medium accentuates density differences. Explain procedure to patient. Determine sensitivity to iodine if contrast material is used.
Magnetic resonance imaging (MRI) Noninvasive procedure using radiofrequency waves and a magnetic field. Procedure is used to detect hepatic metastases and sources of GI bleeding and to stage colorectal cancer. Explain procedure to patient. Contraindicated in patient with metal implants (e.g., pacemaker) or who is pregnant.
Virtual colonoscopy Technique combines CT scanning or MRI with computer virtual reality software to detect colon and bowel diseases, including polyps, colorectal cancer, diverticulosis, and lower GI bleeding. Air is introduced via a tube placed in rectum to enlarge colon to enhance visualization. Images are obtained while patient is on back and stomach. Computer combines images to form 2- and 3-D pictures, which are viewed on monitor. Bowel preparation similar to colonoscopy (see Colonoscopy later in Table). Unlike conventional colonoscopy, no sedatives are needed and no scope is used. Procedure takes about 15–20 min.
Cholangiography    

After local anesthesia, liver is entered with long needle (under fluoroscopy), bile duct is entered, bile withdrawn, and radiopaque contrast medium injected. Fluoroscopy is used to determine filling of hepatic and biliary ducts. Observe patient for signs of hemorrhage or bile leakage. Assess patient’s medication for possible contraindications, precautions, or complications with the use of contrast medium.

Study is performed during surgery on biliary structures, such as gallbladder. Contrast medium is injected into common bile duct. Explain to patient that anesthetic will be used. Assess patient’s medication for possible contraindications, precautions, or complications with the use of contrast medium.

Noninvasive study uses MRI technology to obtain images of biliary and pancreatic ducts. Same as MRI.
Nuclear imaging scans (scintigraphy) Purpose is to show size, shape, and position of organ. Functional disorders and structural defects may be identified. Radionuclide (radioactive isotope) is injected IV and a counter (scanning) device picks up radioactive emission, which is recorded on paper. Only tracer doses of radioactive isotopes are used. Tell patient that substances contain only traces of radioactivity and pose little to no danger. Schedule no more than one radionuclide test on the same day. Explain to patient need to lie flat during scanning.

Radionuclide study is used to assess ability of stomach to empty solids or liquids. In solid-emptying study, cooked egg white containing Tc-99m is eaten. In liquid-emptying study, orange juice with Tc-99m is drunk. Sequential images from gamma camera are recorded q2min for up to 60 min. Study is used in patients with emptying disorders from peptic ulcer, ulcer surgery, diabetes, or gastric malignancies. Same as above.

Patient is given IV injection of Tc-99m and positioned under camera to record distribution of tracer in the liver, biliary tree, gallbladder, and proximal small bowel. Useful for identifying diffuse hepatic disease (such as cirrhosis or neoplasm), as well as for confirming acute cholecystitis. Same as above.

Tc-99m–labeled sulfur colloid or Tc-99m labeling of the patient’s own red blood cells (RBCs) can accurately determine the site of active GI blood loss. The sulfur colloid or the patient’s RBCs are injected, and images of the abdomen are obtained intermittently. Same as above.
Endoscopy    
Esophagogastroduodenoscopy (EGD) Technique directly visualizes mucosal lining of esophagus, stomach, and duodenum with flexible, fiberoptic endoscope. Test may use video imaging to visualize stomach motility. Inflammations, ulcerations, tumors, varices, or Mallory-Weiss tear may be detected. Biopsies may be taken and varices can be treated with band ligation or sclerotherapy.
Colonoscopy Study directly visualizes entire colon up to ileocecal valve with flexible fiberoptic scope. Patient’s position is changed frequently during procedure to assist with advancement of scope to cecum. Test is used to diagnose inflammatory bowel disease, detect tumors, diagnose diverticulosis, and dilate strictures. Procedure allows for biopsy and removal of polyps without laparotomy.
Capsule endoscopy Patient swallows a capsule with camera (approximately the size of a large vitamin) that provides endoscopic evaluation of GI tract. Most commonly used to visualize small intestine and diagnose diseases such as Crohn’s disease, celiac disease, and malabsorption syndrome and to identify sources of possible GI bleeding in areas not accessible by upper endoscopy or colonoscopy. Camera takes about 57,000 images during 8-hr examination. Capsule relays images to data recorder that patient wears on belt. After examination, images are downloaded to monitor.
Sigmoidoscopy Study directly visualizes rectum and sigmoid colon with lighted flexible endoscope. Sometimes special table is used to tilt patient into knee–chest position. Test may detect tumors, polyps, inflammatory and infectious diseases, fissures, and hemorrhoids. Administer enemas evening before and morning of procedure. Patient may have clear liquids day before, or no dietary restrictions may be necessary. Explain to patient knee–chest position (unless patient is older or very ill), need to take deep breaths during insertion of scope, and possible urge to defecate as scope is passed. Encourage patient to relax and let abdomen go limp. Observe for rectal bleeding after polypectomy or biopsy.
Endoscopic retrograde cholangiopancreatography (ERCP) Fiberoptic endoscope (using fluoroscopy) is inserted through the oral cavity into descending duodenum; then common bile and pancreatic ducts are cannulated. Contrast medium is injected into ducts and allows for direct visualization of structures. Technique can also be used to retrieve a gallstone from distal common bile duct, dilate strictures, obtain biopsy of tumors, and diagnose pseudocysts.
Endoscopic ultrasound Combined use of endoscopy and ultrasound using an ultrasound transducer attached to an endoscope. Enables visualization of the esophagus, stomach, intestine, liver, pancreas, and gallstones. Similar to upper GI endoscopy.
Laparoscopy (peritoneoscopy) Peritoneal cavity and contents are visualized with laparoscope. Biopsy specimen may also be taken. Done under general anesthesia in operating room. Double-puncture peritoneoscopy permits better visualization of abdominal cavity, especially liver. Technique can eliminate need for exploratory laparotomy in many patients. Make sure signed consent form is on chart. Keep patient NPO 8 hr before study. Administer preoperative sedative medication. Ensure that bladder and bowel are emptied. Instruct patient that local anesthetic is used before scope insertion. Observe for possible complications of bleeding and bowel perforation after the procedure.
Blood Chemistries    
Serum amylase Study measures secretion of amylase by pancreas and is important in diagnosing acute pancreatitis. Level of amylase peaks in 24 hr and then drops to normal in 48–72 hr. Depending on method, normal finding is 0–130 U/L (0–2.17 μkat/L). Obtain blood sample in acute attack of pancreatitis. Explain procedure to patient.
Serum lipase Study measures secretion of lipase by pancreas. Level stays elevated longer than serum amylase. Normal finding is 0–160 U/L (0–2.66 μkat/L) Explain procedure to patient.
Liver biopsy Percutaneous procedure uses needle inserted between sixth and seventh or eighth and ninth intercostal spaces on the right side to obtain specimen of hepatic tissue. Often done using ultrasound or CT guidance. Before the procedure, check patient’s coagulation status (prothrombin time, clotting or bleeding time). Ensure that patient’s blood is typed and cross-matched. Take vital signs as baseline data. Explain holding of breath after expiration when needle is inserted. Ensure that informed consent has been signed.
    After the procedure, check vital signs to detect internal bleeding q15min × 2, q30min × 4, q1hr × 4. Keep patient lying on right side for minimum of 2 hr to splint puncture site. Keep patient in bed in flat position for 12–14 hr. Assess patient for complications such as bile peritonitis, shock, and pneumothorax.
Miscellaneous Tests    
Gastric analysis Purpose is to analyze gastric contents for acidity and volume. NG tube is inserted, and gastric contents are aspirated. Contents are analyzed mainly for HCl acid, but pH, pepsin, and electrolytes may be determined. Histalog and pentagastrin may be used to stimulate HCl acid secretion. Exfoliative cytology may be done to determine whether malignant cells are present. With fasting, normal acidity is 2.5 mEq/L (2.5 mmol/L) and normal volume is 62 mL/hr; 30 min after Histalog or pentagastrin administration, normal acidity is 1.5 mEq/L (1.5 mmol/L) and normal volume is 110 mL/hr. Keep patient NPO for 8–12 hr. Explain insertion of NG tube. Withhold drugs affecting gastric secretions 24–48 hr before test. Ensure no smoking morning of test (nicotine increases gastric secretion).
Fecal analysis Form, consistency, and color are noted. Specimen examined for mucus, blood, pus, parasites, and fat content. Tests for occult blood (guaiac test, Hemoccult, Hematest) are done. Observe patient’s stools. Collect stool specimens. Check stools for blood with Hemoccult or Hematest. Keep diet free of red meat for 24–48 hr before guaiac test.
Stool culture Tests for the presence of bacteria, including Clostridium difficile. Collect stool specimen.


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NPO, Nothing by mouth; IV, intravenous; NG, nasogastric.


From Lewis S, Heitkemper M, Dirksen S, O’Brien B: Medical-surgical nursing: assessment and management of clinical problems, ed 7, St Louis, 2007, Mosby.



Gingivitis and Periodontitis


The gingivae, or gums, are subject to localized and systemic diseases, problems caused by drug therapy, poor oral hygiene, and poor nutrition. Gingivitis, an inflammation of the gums surrounding the teeth, may result in pain and bleeding; it can lead to periodontitis, a spreading of the inflammation to the underlying tissues, bones, or roots of the teeth. This is the most common reason for tooth loss with advancing age. Gingivitis resulting from overgrowth of the gingivae may occur in people taking phenytoin (Dilantin) on a long-term basis.


Candida albicans, or thrush, is an infection causing white lesions on the oral mucosa. It is often seen in persons with compromised immune systems and in those with suppressed immunity, such as individuals taking immunosuppressant drugs and antibiotics. The condition is most common in denture-bearing tissues of the mouth. The client may complain of an unpleasant taste, burning, or itching or may be asymptotic (Duthie, Katz, & Malone, 2007).



Nursing Management


image Assessment


Assessment begins with a good history of dental care and dental hygiene practices. A complete health history focusing on other illnesses and concomitant medications, as well as a physical assessment of the mouth, is necessary.





image Intervention


Nursing management of an older client with gingivitis or periodontitis includes promotion of regular oral hygiene, regular preventive dental care, and maintenance of nutritional status. In addition, assessing the client’s knowledge of the importance of oral hygiene and frequently reinforcing oral hygiene practices are important roles for the nurse. Oral hygiene includes flossing regularly, brushing teeth or dentures, and using saline mouth rinses as needed. Professional dental care should be sought routinely every 6 months or more often as needed. Proper fit of dentures initially and at all subsequent visits to both the dentist and the primary health care provider is also encouraged. Pain relief, which will facilitate adequate nutrition, can be managed by nonnarcotic pain medications (e.g., acetaminophen or aspirin), frequent mouth rinses, and a liquid or soft diet.


The key to treatment of gingivitis and periodontitis is prevention. Although good oral hygiene needs to begin early in life, it is never too late for an older client to begin routine dental care and oral hygiene. The nurse should discuss with the client the use of nutritional foods that are nonirritating, such as soft foods like pudding and custards, and the use of nutritional supplements like Ensure.




Dysphagia


Dysphagia (difficult swallowing) is a common problem with increased prevalence in the elderly population. Weakened esophageal smooth muscle and incompetent sphincter function are contributory in the elderly who develop dysphagia. Dysphagia is a symptom with many underlying causes, including stroke, neurologic disease (Alzheimer’s disease), local trauma or tissue damage, and tumors that may obstruct the flow of food and liquids in the esophagus. Symptoms may range from mild to severe to a complete inability to swallow (Lewis et al, 2007).


Dysphagia may compromise the nutritional status in the older adult, increase the risk of aspiration pneumonia, and lead to a decreased quality of life.


Nursing care is aimed at ensuring the patient receives adequate nutrition, safe positioning during feeding to prevent aspiration, and thickening liquids to aid the person in swallowing. Occupational therapy with the aim of retraining the patient to swallow is often used in the care and rehabilitation of these older clients.



Nursing Management


image Assessment


Assessment begins with an accurate and precise history that focuses on whether the dysphagia occurs with liquids, solids, or both, as well as the time frame for the progression of the dysphagia. A physical examination may be unremarkable.





image Intervention


Nursing management of an older client with dysphagia includes maintenance of hydration and nutritional status, prevention of aspiration, and provision of emotional support and information regarding the diagnosis and prognosis. Additionally, the nurse provides support and reassurance directed at a client’s fear of eating related to the pain, difficulty in swallowing, and frequent regurgitation. Optimizing nutritional status and preventing weight loss are important because fear of eating may lead to chronic weight loss. Instruction regarding eating habits and maintaining weight and nutrition is important. For example, small, frequent meals, pureed or soft foods, and high-protein, high-calorie foods are helpful. The nurse should instruct the client to elevate the head of the bed to prevent nocturnal aspiration.




Gastroesophageal Reflux and Esophagitis


Gastroesophageal reflux is a prevalent condition in the elderly, found in 20% to 50% of the geriatric population. Causes are diminished esophageal peristalsis, poor clearance of gastric acid, esophageal injury, and a decrease in salivary secretions. The elderly also take medications that can decrease esophageal sphincter pressures. Examples of medications that may induce esophageal injury include tetracycline, alendronate, potassium chloride, quinidine, aspirin, ascorbic acid, nonsteroidal antiinflammatory drugs (NSAIDs), clindamycin, and theophylline. The elderly often take medications lying down, pills may be too large causing injury to the esophagus, and inadequate fluids may be taken with medications and worsen symptoms (Wolfe, 2006).


Esophagitis is simply an inflammation of the esophagus. Most often this results from gastroesophageal reflux caused by either prolonged vomiting or an incompetent lower esophageal sphincter. The amount of mucosal damage is related to the contact time between the esophageal mucosa and the gastric contents, as well as the acidity and quantity of gastric secretions.


Hydrochloric acid from the stomach alters the pH of the esophagus and allows mucosal protein to be denatured. The pepsin in gastric secretions has proteolytic properties that are enhanced when the pH is around 2.0. The combination of pepsin and hydrochloric acid increases the possibility of damage. Reflux has been shown to cause an inflammation that penetrates to the muscularis layer, which results in motor dysfunction and decreased esophageal clearance. The end results are increased esophageal contact time, more muscle damage, and increased amounts of reflux.


Symptoms include heartburn, retrosternal discomfort, and the regurgitation of sour, bitter material. Symptoms are often precipitated by the ingestion of a large amount of fatty or spicy foods or alcohol. Strictures may develop that make food passage difficult. Dysphagia for both liquids and solids increases when severe obstruction occurs. If regurgitation occurs often, substernal pain may result, occasionally mimicking a heart attack. Reflux may be aggravated by postural changes, such as lying supine when sleeping, but may occur in any position. Pulmonary aspiration as a result of reflux is common, when severe; it may lead to pneumonia.



Hiatal Hernia


A hiatal hernia (diaphragmatic or esophageal hernia) is a major cause of reflux and esophagitis and occurs when part of the stomach protrudes through an opening of the diaphragm (Fig. 26–3). The condition may he intermittent or continuous. The continuous type is least common, accounting for only about 10% of cases. Either part or all of the stomach, and even the intestines, may herniate, causing dyspepsia, severe pain, and often a gastric ulceration. The intermittent type, or sliding hernia, occurs with changes in position or with increased peristalsis. The stomach is forced through the opening of the diaphragm when the person is prone and moves back to its normal position when the person stands up. Most hiatal hernias are asymptomatic and require no treatment. Symptoms, when they arise, include heartburn, gastric regurgitation, dysphagia, and indigestion. These symptoms are accentuated (1) when in the supine position after meals, (2) after overeating, (3) after physical exertion, or (4) with a sudden change in posture (Lewis et al, 2007).


Nov 26, 2016 | Posted by in NURSING | Comments Off on Gastrointestinal Function
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