Digestive System

1. Digestive System Chapter 56

2. Structures of Digestive System • Oral Cavity • Esophagus • Stomach • Small intestine • Large intestine • Pancreas • Gallbladder • Liver

3. Teeth, Gums and Mouth • Is the client capable of chewing • Do they have teeth? • What condition are the teeth in? • Are there sores in the mouth that make it painful to chew?

4. Oral Cavity • Chewing mechanically breaks food into smaller particles, which can be swallowed more easily and provide a larger surface area for enzyme action. • Saliva lubricates the food for easier swallowing and initiates the digestion of starches.

5. Esophagus • Can the client swallow? • Do they have a history of GERD, Hiatal hernia or esophageal stricture? • GERD: gastro esophageal reflux disease • Hiatal hernia • Esophageal stricture

6. GERD

7. Esophageal Stricture

8. Hiatal Hernia

9. Esophagus • Main function is to move food from the pharynx to the stomach. • Secretes some mucous and has some peristaltic movement. • Two sphincters: • Upper sphincter prevents air from entering the esophagus during inspiration • Lower esophageal sphincter prevents reflux of acidic gastric contents into the esophagus

10. Secretions of Digestive System • Mucus • Saliva • Gastric juices • Mucous • Digestive enzymes • Hydrochloric acid • Electrolytes

11. Stomach • Serves as a reservoir • Churns and mixes the food with digestive juices: • Secretes mucous • Hydrochloric acid • Enzymes • Starts protein breakdown and secretes intrinsic factor for absorption of vitamin B12 from the ileum • Little absorption of any nutrients or drugs • Highly lipid-soluble substances - some drugs and alcohol – are absorbed • Gastric emptying time is about 4 hours

12. Gastric Juices • Major digestive enzyme of gastric juice is pepsin, a proteolytic enzyme that functions best at a pH of 2 or 3. • Hydrochloric acid provides the acid medium to promote pepsin activity. • Major function of gastric juice is to begin digestion of proteins.

13. Mucous • Mucous is secreted in the stomach to protect the stomach wall from the proteolytic action of pepsin. • When mucous is not secreted, gastric ulceration occurs.

14. Pancreatic Juices • Pancreatic juices are alkaline (pH of 8 or above). • Contains amylase for carbohydrate digestion, lipase for fat digestion, and trypsin and chymotrypsin for protein digestion. • Contains sodium bicarbonate a base that neutralizes the acid from the stomach.

15. Small Intestine • Consists of duodenum, jejunum, ileum • Pancreatic and bile ducts empty into the duodenum • Secretes digestive enzymes, hormones and mucous • Digestion and absorption occurs – including most orally administered drugs

16. Large Intestine • Consists of cecum, colon, rectum, and anus • Main function is elimination

17. Nutritional Support Products, Vitamins, and Mineral-Electrolytes Chapter 57

18. Nutrients • Water, carbohydrates, proteins, fats, vitamins and minerals are required to promote and maintain health and prevent illness. • Vitamins are required for normal body metabolism, growth, and development.

19. Nutritional Deficiency • Clients are unable to ingest, digest, absorb or utilize sufficient nutrients to improve or maintain health.

20. Nutritional Products • Liquid enteral products • Intravenous fluids • Pancreatic enzymes • Vitamins • Minerals - electrolytes

21. Liquid Enteral Products

22. Liquid Formulas • OTC preparation for oral or tube feedings • Nutritionally complete except for water • Special formulas for clients with renal or hepatic failure • High protein for increased calories

23. Nursing Responsibilities • Read can to make sure the supplement ordered is correct. • Calories per ounce and additives may differ. • Make sure client drinks water. • Especially important on clients dependant on care takers for fluid intake – gastrostomy tube feeds.

24. Intravenous Solutions • Used when oral fluids or tube feedings are contraindicated. • Used short term to provide fluids and electrolytes. • Dextrose and sodium chloride major solution used • Dextrose 5% in 0.2 % normal saline • Dextrose 5% in 0.45 % normal saline

25. Potassium Chloride • Most common additive: • potassium chloride or KCL • Usual dose KCL 2 mEq / 100 mL of IV solution. • KCL is considered a medication and needs to be charted on MAR (medication administration record).

26. Total Parenteral Nutrition • Long-term use from weeks to months to provide all nutrients required for normal body functions – growth and tissue repair. • Usually administered through central line. • Fluids often have high concentration of dextrose 5 % or 10% along with extra minerals. • Proteins and lipids are given IV through special filters. • Must go in at prescribed rate – no catching up on fluids.

27. Vitamin Supplements • Most often self supplied • Billion dollar OTC industry • Preparations should not included more than recommended amounts of vitamin D, folic acid and vitamin A • Most are synthetic preparations • Most contain minerals – large doses of all minerals are toxic

28. Minerals - Electrolytes • 22 minerals • Calcium and phosphorus have major role in bone metabolism • Electrolytes - Body must contain equal number of negative and positive charges • Adequate amounts contained in protein foods so extra intake is not needed if diet is adequate • Most common dietary deficiency: calcium and iron

29. Calcium - Iron Calcium supplements - most adolescent and adult females would benefit from calcium supplements (1000 to 1300 mg daily). Iron supplements – often used during periods of increase need – pregnancy. Iron should not be taken otherwise due to high risk for accumulation and toxicity.

30. Drugs to Aid Weight Management Chapter 58

31. Overweight / Obese Adults • 60% of adults are overweight or obese • Etiology • Physiologic factors • Genetic factors • Environmental factors • Psychosocial factors - depression

32. BMI • BMI calculations: www.cdc.gov • Desired BMI is 18.5 to 24.9 • Extremes may represent underweight or overweight / obese • Insurance companies are using BMI calculations to determine health insurance coverage.

33. Diseased Related to Obesity • Cancer • Cardiovascular disease • Diabetes type II • Dyslipidemia (high cholesterol) • Gallstones

34. Drug Therapy • BMI greater than 30 • Part of a weight management program – exercise – decrease in calorie intake • Once drugs stopped weight gain tends to re-occur

35. Drugs Used in Weight Loss • Appetite suppressants • phentermine • sibutramine • Fat blockers • Orlistat

36. Phentermine • Brand names: Adipex-P, Obenix, Oby-Trim • Classification pharmacologic: anorectics • Classification therapeutic: appetite suppressant • Action: decrease appetite by possible changing brain levels of serotonin. Phentermine is a nervous system stimulator like the amphetamines causing stimulation, elevation in blood pressure, and increased heart rate.

37. Sibutramine • Brand name: Meridia • Classification pharmacologic: appetite suppressant • Classification therapeutic: weight control agent • Action: Acts as an inhibitor of the reuptake of serotonin, norepinephrine and dopamine; increases the anxiety-producing effects of serotonin.

38. Contraindications to Use • Pregnancy and lactation • Patients with severe hepatic or renal disease. • Uncontrolled hypertension • CHF or cardiovascular disease

39. Side Effects • CNS stimulation: confusion, dizziness, euphoria, headache, insomnia, restlessness • Heart palpitations, hypertension, tachycardia • Changes in libido or impotence

40. Orlistat • Brand name: Xenical • Classification pharmacologic: lipase inhibitor • Classification therapeutic: weight control agent • Action: Decreases the absorption of dietary fat by reversibly inhibiting enzyme (lipases), which are necessary for the breakdown and subsequent adsorption of fat. • Therapeutic effect: weight loss

41. Orlistat • Side effects: fecal urgency, flatus, increased defecation, oily evacuation, fecal incontinence

42. Drugs Used for Peptic Ulcer and Acid Reflux Disorders Chapter 59

43. Peptic Ulcer Disease • Ulcer formation in the esophagus, stomach or duodenum • Mucous exposed to gastric acid and pepsin • Imbalance between cell-destructive and cell-protective effects • Gastric acid and pepsin • H. pylori – infectious process

44. Peptic Ulcer Disease

45. Gastric Ulcers • Ulcer of stomach • Associated with stress • NSAID ingestion (non-steroidal anti-inflammatories) • H. pylori • Alcohol consumption • Smoking • More likely to occur in older adults

46. Duodenal Ulcer or Peptic Ulcer • Ulcer found in the duodenum or upper portion of the small intestine • Associated with H. pylori and NSAIDs • Higher incidence in smokers

47. Sign and Symptoms • Burning pain in abdomen between breastbone and belly button. • Nausea / vomiting • Chest pain (dull and achy) • Loss of appetite • Frequent burping or hiccupping • Blood in vomit or bowel movement

48. Diagnosis • Upper endoscopy: patient is put under sedation and a small flexible tube with a tiny camera on the end is inserted through the mouth, down the esophagus into the stomach and duodenum. • pH probe to measure acid going to the area • Biopsy to test for H. pylori

49. Endoscopic Exam

50. Treatment • Antibiotics: H. pylori: amoxicillin and metronidazole (Flagyl) • Acid blockers: histamine H-2 blockers: Zantac, Pepcid, Tagamid and Axid (OTC) • Antacids • Proton pump inhibitors (prescription): Prilosec, Prevacid, Aciphex and Nexium. • Cytoprotective agents: Carafate, Cytotec or OTC Pepto-Bismol