CH. 44 Introduction to the Gastrointestinal System and Accessory Structures

A client asks the nurse why the physician ordered the blood test carcinoembryonic antigen (CEA). The nurse answers:

"It indicates if a cancer is present." Explanation: The carcinoembryonic antigen (CEA) blood test detects the presence of cancer by identifying the presence of a protein not normally detected in the blood of a healthy person. However, it does not indicate what type of cancer is present nor does it detect the functionality of the liver.

NON-RADIOGRAPHIC STUDIES - Difference between MRI & MRE

(MRI) Magnetic Resonance Imaging - Uses magnetic energy rather than radiation; examines GI structures; oral contrast agents (MRE) Magnetic Resonance Elastography - MRI + low-frequency sound waves

A client with a gastrointestinal condition asks why the mouth needs to be examined. Which response will the nurse make?

- "Changes in the mouth can help explain why your condition is occurring." Explanation: A complete assessment of the oral cavity is essential because many disorders, such as cancer, diabetes, and immunosuppressive conditions resulting from medication therapy or acquired immunodeficiency syndrome, may be manifested by changes in the oral cavity, including stomatitis (inflammation of oral mucosa, white lesions & painful)n

A client presents at the ambulatory clinic reporting recurrent sharp stomach pain that is relieved by eating. The nurse suspects that the client may have an ulcer. How should the nurse explain the formation and role of acid in the stomach to the client?

- "Hydrochloric acid is secreted by glands in the stomach in response to the actual or anticipated presence of food." Explanation: The stomach, which stores and mixes food with secretions, secretes a highly acidic fluid in response to the presence or anticipated ingestion of food. The stomach does not turn food directly into acid and the esophagus is not highly alkaline. Pancreatic enzymes are not synthesized in a highly acidic environment.

A home care nurse is caring for a client with reports of epigastric discomfort who is scheduled for a barium swallow. Which statement by the client indicates an understanding of the test?

- "I'll avoid eating or drinking anything 6 to 8 hours before the test." Explanation: The client demonstrates understanding of a barium swallow when stating he or she must refrain from eating or drinking for 6 to 8 hours before the test. No other preparation is needed. Before a lower GI series, the client should eat a low-residue or clear liquid diet for 2 days and take a potent laxative and an oral liquid preparation.

A nurse is providing preprocedure education for a client who will undergo a lower GI tract study the following week. What should the nurse teach the client about bowel preparation?

- "You'll need to have enemas the day before the test." Explanation: Preparation of the client includes emptying and cleansing the lower bowel. This often necessitates a low-residue diet 1 to 2 days before the test; a clear liquid diet and a laxative the evening before; NPO after midnight; and cleansing enemas until returns are clear the following morning.

A client has been brought to the emergency department with abdominal pain and is subsequently diagnosed with appendicitis. The client is scheduled for an appendectomy but questions the nurse about how a person's health is affected by the absence of the appendix. How should the nurse best respond?

- "Your appendix doesn't play a major role in health, so you won't notice any difference after your recovery from surgery." Explanation: The appendix is an appendage of the cecum (not the small intestine) that has little or no physiologic function. Its absence does not affect digestion or absorption.

It is suspected that a client might have a problem in the duodenum and the client is scheduled to have GI studies done in the morning. In client education, the nurse describes the procedure and includes basic information about anatomy and the function of the organs involved. The client asks how long the duodenum is. What is the nurse's best response?

- 10 inches Explanation: The duodenum is approximately 10 inches long and is the first region of the small intestine.

ENTEROCLYSIS - Define Enteroclysis

- A test performed to examine the small bowel. A tube is placed down the nose and throat, through the stomach into the small intestine. When in place, contrast dye is introduced (small bowel enema) and x-ray images are viewed on a fluoroscopic monitor to visualize how the contrast moves through the bowel structures

Which of the following digestive enzymes aids in the digesting of starch?

- Amylase Explanation: Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein; amylase, which aids in digesting starch lipase, which aids in digesting fats. Bile is secreted by the liver and is not considered a digestive enzyme.

A nurse is caring for a client with recurrent hematemesis who is scheduled for upper gastrointestinal fibroscopy. How should the nurse in the radiology department prepare this client?

- Apply local anesthetic to the back of the client's throat. Explanation: Preparation includes spraying or gargling with a local anesthetic. A nasogastric tube or a micro Fleet enema is not required for this procedure. The client should be positioned in a side-lying position in case of emesis.

A client has come to the outpatient radiology department for diagnostic testing that will allow the care team to evaluate and remove polyps. The nurse should prepare the client for what procedure?

- Colonoscopy Explanation: During colonoscopy, tissue biopsies can be obtained, as needed, and polyps can be removed and evaluated. This is not possible during a barium enema, ERCP, or gastroscopy.

A nurse is performing an abdominal assessment of an older adult client. When collecting and analyzing data, the nurse should be cognizant of what age-related change in gastrointestinal structure and function?

- Decreased mucus secretion Explanation: Older adults tend to secrete less mucus than younger adults. Gastric motility slows with age and gastric pH rises due to decreased secretion of gastric acids. Older adults tend to have a blunted gag reflex compared to younger adults.

A nurse is preparing a client with Crohn's disease for a barium enema. What should the nurse do the day before the test?

- Encourage plenty of fluids. Explanation: The nurse should encourage plenty of fluids because adequate fluid intake is necessary to avoid dehydration that may be caused by the bowel preparation and to prevent fecal impaction after the procedure. The client may be placed on a low-residue diet 1 to 2 days before the procedure to reduce the contents in the GI tract. Fiber intake is limited in a low-residue diet. Because dairy products leave a residue, they aren't allowed the evening before the test. Clear liquids only are allowed the evening before the test.

An older client reports difficulty chewing and swallowing. Which age-related changes will the nurse suspect as the reasons for the client's symptoms? Select all that apply.

- Explanation: Age-related changes to the oral cavity and pharynx can cause difficulty chewing and swallowing. These changes include a: - loss of teeth - atrophy of taste buds - reduced saliva production - less ptyalin and amylase in saliva - a weakened gag reflex.

An adult client is scheduled for an upper GI series that will use a barium swallow. What teaching should the nurse include when the client has completed the test?

- Fluids must be increased to facilitate the evacuation of the stool. Explanation: Postprocedural client education includes information about increasing fluid intake; evaluating bowel movements for evacuation of barium; and noting increased number of bowel movements. The number of bowel movement is noted because barium, due to its high osmolarity, may draw fluid into the bowel, thus increasing the intraluminal contents and resulting in greater output. Yellow stool, diarrhea, and anal bleeding are not expected.

A clinic client has described recent dark-colored stools, and the nurse recognizes the need for fecal occult blood testing (FOBT). What aspect of the client's current health status would contraindicate FOBT?

- Hemorrhoids Explanation: FOBT should not be performed when there is hemorrhoidal bleeding. GERD, peptic ulcers, and nausea and vomiting do not contraindicate the use of FOBT as a diagnostic tool.

A client with abdominal pain is scheduled for a CT scan of the abdomen with contrast. Which assessment will the nurse complete before transporting the client for the diagnostic test?

- History of allergies Explanation: A CT scan provides cross-sectional images of abdominal organs and structures. A CT scan may be performed with or without oral or intravenous (IV) contrast, but the enhancement of the study is greater with the use of a contrast agent. A common risk from IV contrast agents is allergic reactions; therefore, the client must be screened for this risk. Any allergies to contrast agents, iodine, or shellfish must be determined before administration of a contrast agent. Clients allergic to the contrast agent may be premedicated with a corticosteroid and antihistamine. Therefore, a history of allergies must be completed before the test. Assessing for the presence of a cochlear implant is recommended before magnetic resonance imaging (MRI), but not before a CT scan.

A nurse has auscultated a client's abdomen and noted one or two bowel sounds in a 2-minute period of time. How should the nurse document the client's bowel sounds?

- Hypoactive Explanation: Documenting bowel sounds is based on assessment findings. The terms : - normal (sounds heard about every 5 to 20 seconds) - hypoactive (one or two sounds in 2 minutes) - hyperactive (5 to 6 sounds heard in less than 30 seconds) - absent (no sounds in 3 to 5 minutes) are frequently used in documentation. Paralytic ileus is a medical diagnosis that may cause absent or hypoactive bowel sounds, but the nurse would not independently document this diagnosis.

A nurse is caring for a client who is scheduled for a colonoscopy and whose preparation will include polyethylene glycol electrolyte lavage prior to the procedure. The presence of what health problem would contraindicate the use of this form of bowel preparation?

- Inflammatory bowel disease Explanation: The use of a lavage solution is contraindicated in clients with intestinal obstruction or inflammatory bowel disease. It can safely be used with clients who have polyps, colon cancer, or diverticulitis.

A client is scheduled for an upper gastrointestinal barium study. Which teaching will the nurse provide for the client to prepare for this diagnostic test?

- Ingest nothing by mouth after midnight. Explanation: An upper GI fluoroscopy delineates the entire GI tract after the introduction of a contrast agent such as barium. To prepare for the test, the client should be instructed to ingest nothing after midnight before the test. Clear liquids are not permitted the morning of the test. Most oral medications are withheld the morning of the test, but not for 24 hours before. There is no reason to avoid products containing aspirin for a week before the test.

The nurse is preparing to perform a client's abdominal assessment. What examination sequence should the nurse follow?

- Inspection, auscultation, percussion, and palpation Explanation: When performing a focused assessment of the client's abdomen, auscultation should always precede percussion and palpation because they may alter bowel sounds

The nurse is caring for a geriatric client and notices polypharmacy. Which diagnostic studies are anticipated?

- Liver function studies Explanation: The liver metabolizes and biotransforms the medications ingested. Geriatric clients who experience polypharmacy or multiple medications have an elevated risk of liver impairment. Routine liver function studies monitor the status of the liver and its ability to metabolize.

A nurse is caring for clients in a stroke rehabilitation facility. Damage to what area of the brain will most affect a client's ability to swallow?

- Medulla oblongata Explanation: Swallowing is a voluntary act that is regulated by a swallowing center in the medulla oblongata of the central nervous system

The nurse is assisting the health care provider with a gastric acid stimulation test for a client. What medication should the nurse prepare to administer subcutaneously to stimulate gastric secretions?

- Pentagastrin Explanation: The gastric acid stimulation test usually is performed in conjunction with gastric analysis. Histamine or pentagastrin is administered subcutaneously to stimulate gastric secretions.

The nurse is preparing to assess the abdomen of a client experiencing a gastrointestinal condition. Place in order the actions the nurse will take to complete this assessment.

- Position supine. - Flex the knees. - Inspect the skin. - Auscultate bowel sounds. - Percuss abdominal organs. - Palpate for tenderness and masses.

The nurse is assisting the health care provider with a colonoscopy for a client with rectal bleeding. The health care provider requests the nurse to administer glucagon during the procedure. Why is the nurse administering this medication during the procedure?

- To relax colonic musculature and reduce spasm. Explanation: Glucagon may be administered, if needed, to relax the colonic musculature and to reduce spasm during the colonoscopy.

TRUE or FALSE Upper gastrointestinal series identify structural abnormalities of the esophagus, swallowing dysfunction, and oral aspiration.

- True Rationale: Upper gastrointestinal series identify structural abnormalities of the esophagus, swallowing dysfunction, and oral aspiration.

A nurse is caring for a newly admitted client with a suspected GI bleed. The nurse assesses the client's stool after a bowel movement and notes it to be a tarry-black color. This finding is suggestive of bleeding from what location?

- Upper GI tract Explanation: Blood shed in sufficient quantities in the upper GI tract will produce a tarry-black color (melena). Blood entering the lower portion of the GI tract or passing rapidly through it will appear bright or dark red. Lower rectal or anal bleeding is suspected if there is streaking of blood on the surface of the stool or if blood is noted on toilet tissue.

A client who has been in a motor-vehicle collision is comatose and has developed ascites as a result of the accident. The nurse explains the condition to the client's family, and indicates that the primary function of the small intestine is to:

- absorb nutrients Explanation: The primary function of the small intestine is to absorb nutrients from the chyme.

When gastric analysis testing reveals excess secretion of gastric acid, the nurse recognizes which medical diagnoses is supported?

- duodenal ulcer Explanation: Clients with duodenal ulcers usually secrete an excess amount of hydrochloric acid. Clients with chronic atrophic gastritis secrete little or no acid. Clients with gastric cancer secrete little or no acid. Clients with pernicious anemia secrete no acid under basal conditions or after stimulation.

Cystic fibrosis, a genetic disorder characterized by pulmonary and pancreatic dysfunction, usually appears in young children but can also affect adults. If the pancreas was functioning correctly, where would the bile and pancreatic enzymes enter the GI system?

- duodenum Explanation: The duodenum, which is approximately 10 inches long, is the first region of the small intestine and the site where bile and pancreatic enzymes enter.

Which term describes a gastric secretion that combines with vitamin B12 so that it can be absorbed?

- intrinsic factor Explanation: Intrinsic factor, secreted by the gastric mucosa, combines with dietary vitamin B12 so that the vitamin can be absorbed in the ileum. In the absence of intrinsic factor, vitamin B12 cannot be absorbed and pernicious anemia results. Amylase is an enzyme that aids in the digestion of starch. Pepsin, an important enzyme for protein digestion, is the end product of the conversion of pepsinogen from the chief cells. Digestive enzymes secreted by the pancreas include trypsin, which aids in digesting protein.

A client tells the nurse that the stool was colored yellow. The nurse assesses the client for

- recent foods ingested. Explanation: The nurse should assess for recent foods that the client ingested, as ingestion of senna can cause the stool to turn yellow. - Bismuth = black stool - occult blood = tarry black stool

Which procedure is performed to examine and visualize the lumen of the small bowel?

- small bowel enteroscopy Explanation: Small bowel enteroscopy is the endoscopic examination and visualization of the lumen of the small bowel. Colonoscopy is the examination of the entire large intestine with a flexible fiberoptic colonoscope. Panendoscopy is the examination of both the upper and lower GI tracts. Peritoneoscopy is the examination of GI structures through an endoscope inserted percutaneously through a small incision in the abdominal wall.

A nurse is teaching a client with malabsorption syndrome about the disorder and its treatment. The client asks which part of the GI tract absorbs food. What is the nurse's best response?

- small intestine Explanation: The small intestine: - absorbs products of digestion - completes food digestion - secretes hormones that help control the secretion of bile, pancreatic juice, and intestinal secretions. The stomach: - stores - mixes - liquefies the food bolus into chyme and controls food passage into the duodenum; it doesn't absorb products of digestion. The large intestine: - completes the absorption of water, chloride, and sodium, it plays no part in absorbing food. The rectum is the portion of the large intestine that forms and expels feces from the body; its functions don't include absorption.

In regards to G.i health what 7 manifestations should you as a Nurse focus on?

1. Any abdominal pain 2. Issues with digestion 3. Nausea/vomiting 4. Constipation 5. Diarrhea 6. Incontinence 7. other complaints.

The History of a patient includes what 3 things?

1. Chief complaint 2. Focused assessment of: - current nutritional patterns - metabolic patterns - elimination patterns 3. Past history

G.I LAB TESTS - List the 12 lab tests

1. Complete blood count 2. Urinalysis 3. Serum bilirubin 4. Cholesterol 5. Serum ammonia level 6. Prothrombin time 7. Protein electrophoresis 8. Enzymes 9. Common tumor marker blood studies 10. Gastric analysis (H. pylori test) 11. Hydrogen breath testing 12. Stool analysis

List the 7 areas that a G.i physical Nursing assessment consists of

1. General appearance 2. Skin 3. Mouth 4. Abdomen 5. Anus

What 6 nursing managements are done after a Liver Biopsy?

1. Pre-op: Patient should Lie quietly on right side for 2 hours 2. Post-op: 8 to 12 hours in bed 3. Take VS 4. Monitor bleeding, swelling, or hematoma 5. Listen to Breath sounds

Name the 14 types of G.i Diagnostic tests

1. Radiographic studies 2. Barium swallow or Upper G.i series 3. Small Bowel Series 4. Enteroclysis 5. Barium Enema or Lower G.i Series 6. Oral Cholecystography or Gallbladder Series 7. Cholangiography 8. Radionuclide Imaging 9. Computed Tomography 10. Nonradiographic Studies 11. Ultrasonography 12. Percutaneous Liver Biopsy 13. Gastrointestinal Endoscopy 14. Lab tests

After a liver biopsy, how many hours should a patient stay in bed? A. 1 to 4 hours B. 4 to 8 hours C. 8 to 12 hours D. 12 to 16 hours

C. 8 to 12 hours Rationale: After a liver biopsy, a patient should stay in bed for 8 to 12 hours.

The nurse auscultates the abdomen to assess bowel sounds. She documents five to six sounds heard in less than 30 seconds. How does the nurse document the bowel sounds?

Hyperactive Explanation: Bowel sounds are assessed using the diaphragm of the stethoscope for high-pitched and gurgling sounds (Gu, Lim, & Moser, 2010). The frequency and character of the sounds are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minute. - normal (sounds heard about every 5 to 20 seconds) - hypoactive (one or two sounds in 2 minutes) - hyperactive (5 to 6 sounds heard in less than 30 seconds) - absent (no sounds in 3 to 5 minutes) are frequently used in documentation, but these assessments are highly subjective

RADIONUCLIDE IMAGING - Purpose of Radionuclide Imaging? - How is Procedure done?

PURPOSE - Detects lesions of liver or pancreas and assists in evaluating gastric emptying PROCEDURE - Injected IV or ingested orally

PERCUTANEOUS LIVER BIOPSY - Purpose of Percutaneous Liver Biopsy - What 4 things does it detect?

PURPOSE - Obtains liver tissue and examine microscopically - Usually to see if patient has Cancer - Detects: 1. malignant changes 2. infectious or inflammatory processes 3. Liver damage 4. Signs of rejection in clients who have received a liver transplant

CHOLANGIOGRAPHY - Purpose of Cholangiography? - When is this procedure used? - 4 Types of Cholangiography

PURPOSE Determines the patency of the ducts from the liver and gallbladder USED WHEN - gallbladder not distinctly visible - vomiting interferes with oral dye TYPES OF CHOLANGIOGRAPHY 1. ERCP (Endoscopic retrograde cholangiopancreatography) - procedure to Dx & Tx problems in the liver, gallbladder, bile ducts & pancreas 2. Intraoperative cholangiography - a special kind of X-ray imaging that shows bile ducts, used during surgery. 3. MRCP (Magnetic resonance cholangiopancreatography) - a special type of MRI exam that produces detailed images of the hepatobiliary and pancreatic systems, including the liver, gallbladder, bile ducts, pancreas and pancreatic duct 4. PTC (Percutaneous transhepatic cholangiography) - a radiological technique used to visualize the anatomy of the biliary tract. A contrast medium is injected into a bile duct in the liver, after which X-rays are taken

SMALL BOWEL SERIES - Purpose of small bowel series?

PURPOSE Identifies: - obstruction in jejunum or ileum - tumors - inflammation

BARIUM ENEMA or LOWER G.i SERIES - Purpose of Barium Enema? - What 3 areas does it observe fluoroscopically? - 5 Nursing Management

PURPOSE Identifies: - polyps - tumors - inflammation - strictures - abnormalities of the colon OBSERVE fluoroscopically 1. Rectum 2. Sigmoid colon 3. Descending colon NURSING MANAGEMENT 1. Position changes 2. Retain the instilled barium 3. Stool specimens 4. Restrictions and procedures to reduce the formation of stool 5. Remove any residual stool

RADIOGRAPHIC STUDIES - Purpose of Radiographic Studies? - What type of diagnostic drug and medical procedure fall under the Radiographic study category?

PURPOSE Identify location, structural appearance of organs in: - abdomen - chest - GI system 1. Radiopaque contrast media (diagnostic DRUGS used for the enhancement of radiographic examinations) 2. Fluoroscopy (a MEDICAL PROCEDURE that makes a real-time video of the movements inside a part of the body by passing x-rays through the body over a period of time)

BARIUM SWALLOW or UPPER G.i SERIES - Purpose of Barium Swallow or Upper G.i Series? - What 2 observations fall under the Barium Swallow or Upper G.i Series? - Pre-procedure requisites? - Post-procedure requisites?

PURPOSE Identify structural abnormalities of: - esophagus - swallowing dysfunction - oral aspiration OBSERVATIONS 1. Fluoroscopic observation (esophagus) 2. Radiographic observation PRE-PROCEDURE - low-residue diet - laxative - No smoking POST PROCEDURE - drink fluids liberally - obtain stool specimens (poop may be chalky white) - laxative

ORAL CHOLECYSTOGRAPHY or GALL BLADDER SERIES - Purpose of Oral Cholecystography or Gallbladder Series? - When should radiography be performed? -

PURPOSE Identify: - Stones in the gallbladder 2. Common bile duct 3. Tumors - ability to store a dyelike, iodine-based, radiopaque contrast medium Radiography: should be performed before other GI examinations - Dye tablets; no eating or drinking; fatty test meal

GASTROINTESTINAL ENDOSCOPY - Purpose of Gastrointestinal Endoscopy, what does it evaluate?

PURPOSE Visual examination of the lumen of the GI tract with a flexible fiberoptic endoscope - Evaluates the appearance and integrity of the GI mucosa; detects lesions

COMPUTED TOMOGRAPHY - Purpose of computed tomography? - How is Procedure done?

PURPOSE - Detects structural abnormalities of the GI tract and metastatic lesions PROCEDURE - Before the test: cleanse bowels - Hollow GI organs: oral barium sulfate or IV calcium phosphate

ULTRASONOGRAPHY - Purpose of Ultrasonography - What 7 things does it detect?

PURPOSE High-frequency sound waves detect: 1. size of organs 2. Location of organs 3. Outlines structures 4. abnormalities 5. cholelithiasis 6. pyloric stenosis 7. appendicitis changes

What is the objective of a patients history?

To identify the client's specific problem and its possible cause