MODULE 1

SUPPLEMENTARY READING

GASTROINTESTINAL SYSTEM
REVIEW OF ANATOMY AND PHYSIOLOGY OF THE
GASTROINTESTINAL SYSTEM
Functions of Gastrointestinal System
A. Digestion of food, essential preparation for absorption and metabolism
B. Absorption of digested food
C. Elimination of wastes of digestion
Digestion
A. Definition: all changes that food undergoes in the alimentary canal
B. Purpose: conversion of foods into chemical and physical forms that can be absorbed and metabolized
C. Kinds
1. Mechanical digestion: all movements of the alimentary tract that:
a. Change physical state of foods from comparatively large solid pieces into minute dissolved particles
b. Propel food forward along the alimentary tract, finally eliminating digestive wastes from the body
(1) Deglutition: swallowing
(2) Peristalsis: wavelike movements that squeeze food downward in the tract
(3) Mass peristalsis: moving of entire intestinal contents into the sigmoid colon and rectum; usually occurs
after a meal
(4) Defecation: emptying of the rectum (bowel movement)
c. Churn intestinal contents so all become well mixed with digestive juices and all parts of contents come
in contact with the intestinal mucosa to facilitate absorption
2. Chemical digestion: series of hydrolytic processes dependent on specific enzymes; hydrolysis,
decomposition of complex compound into two or more simple compounds by means of
chemical reaction with water
D. Control of digestive gland secretion
1. Secretion of saliva: neural control of this reflex results from parasympathetic impulses to glands,
initiated by taste, smell, and sight of food (cephalic phase of digestion)
2. Gastric juice
a. Neural control similar to that of salivary glands
b. Hormonal control: partially digested proteins cause gastric mucosa to release hormone (gastrin) into
blood; gastrin stimulates gastric mucosa to secrete juice with high pepsin and hydrochloric acid content
3. Pancreatic juice
a. Hormonal control: hydrochloric acid in chyme entering the duodenum from the stomach causes
intestinal mucosa to release a hormone, secretin, into the blood; secretin stimulates pancreatic cells to
secrete a juice high in sodium bicarbonate to neutralize hydrochloric acid but low in
enzymes; products of protein digestion (e.g., proteoses, peptones, and amino acids) cause the intestinal
mucosa to release another hormone, pancreozymin, that stimulates the pancreatic cells to secrete
enzymes
b. Neural control: reflex secretion of pancreatic juice results from parasympathetic impulses via the vagus
nerve
4. Bile
a. Although bile is secreted continuously, secretin increases amount of bile secreted
b. Presence of fats in the intestine causes the intestinal mucosa to release a hormone, cholecystokinin,
into the blood; cholecystokinin stimulates the smooth muscle of the
gallbladder to contract, ejecting bile into the duodenum
5. Intestinal juice: control obscure, but believed to be both reflexive
and hormonal; food in the small intestine causes the mucosa to release hormone (enterocrinin) into blood;
enterocrinin stimulates intestinal glands to secrete
Absorption
A. Definition: passage of substances through the intestinal mucosa into the blood or lymph
B. Accomplished mainly through active transport by the intestinal cells; makes it possible for both water
and solutes to move through the intestinal mucosa in a direction opposite that expected in osmosis and
diffusion
C. Absorption occurs in the duodenum and jejunum of the small intestine; however, absorption of alcohol,
certain drugs, and some water occurs in the stomach; most water is absorbed from the large intestine
D. Absorption of protein, carbohydrate, and fat
Metabolism
A. Definition: sum of all the chemical reactions in the body
B. Catabolism
1. Consists of a complex series of chemical reactions that take place inside the cells and yield energy,
carbon dioxide, and water; about half the energy released from food molecules by
catabolism is put back in storage as unstable, high-energy bonds of ATP molecules; the rest is
transformed to heat; the energy in high-energy bonds of ATP can be released as rapidly as needed for
cellular work
2. Two processes involved; glycolysis and the Krebs' cycle with the electron transport chain
3. Purpose: to provide cells continually with utilizable energy
C. Anabolism
1. Synthesis of various compounds from simpler compounds
2. Cellular work that uses some of the energy made available by catabolism
D. Metabolism of carbohydrates
Consists of the following processes:
1. Glucose transport through cell membranes and phosphorylation
a. Insulin promotes this transport through cell membranes
b. Glucose phosphorylation: conversion of glucose to glucose- 6-phosphate, catalyzed by the enzyme
hexokinase (2 X); insulin increases the activity of glucokinase and promotes
glucose phosphorylation, which is essential prior to both glycogenesis and glucose catabolism
2. Glycogenesis: conversion of glucose to glycogen for storage; occurs mainly in the liver and muscle
cells
3. Glycogenolysis
a. In muscle cells glycogen is changed back to glucose-6- phosphate, which is then catabolized in the
muscle cells
b. In liver cells glycogen is changed back to glucose; an enzyme, glucose phosphatase, is present in the
liver cells and catalyzes the final step of glycogenolysis, the changing
of glucose-6-phosphate to glucose; glucagon and epinephrine accelerate liver glycogenolysis
4. Glucose catabolism
a. Glycolysis: series of anaerobic reactions that break one glucose molecule down into two pyruvic acid
molecules, with conversion of about 5% of energy stored in glucose to heat
and ATP molecules
b. Krebs' citric acid cycle with the electron transport chain: series of aerobic chemical reactions by which
two pyruvic acid molecules (from one glucose molecule) are broken down to six carbon dioxide and six
water molecules, with the release of some energy as heat and some stored again in ATP; the aerobic
reactions release about 95% of the energy stored in glucose, while the anaerobic reactions release only
about 5%; the aerobic reactions occur in the mitochondria of
cells
5. Gluconeogenesis: sequence of chemical reactions carried on in liver cells; process converts protein or
fat compounds into glucose
6. Principles of normal carbohydrate metabolism
a. Principle of preferred energy fuel: most cells first catabolize glucose, sparing fats and proteins (muscle
cells prefer fatty acids as long as adequate oxygen is available); when the glucose supply becomes
inadequate, most cells (not nerve cells) next catabolize fats; nerve cells require glucose, thus causing
proteins to be sacrificed to provide the amino acids needed to produce more glucose (gluconeogenesis);
also small amounts of glucose can be made from the glycerol
portion of fats
b. Principle of glycogenesis: glucose in excess of about 120 to 140 mg per 100 ml blood brought to the
liver by the portal veins enters the liver cells, where it undergoes glycogenesis and is stored as glycogen
c. Principle of glycogenolysis: when blood glucose decreases below the midpoint of normal, liver
glycogenolysis accelerates and tends to raise the blood glucose concentration back toward the midpoint
of normal
d. Principle of gluconeogenesis: when blood glucose decreases below normal or when the amount of
glucose entering the cells is inadequate, liver gluconeogenesis accelerates and raises blood glucose
levels
e. Principle of glucose storage as fat: when the blood insulin content is adequate, glucose in excess of the
amount used for catabolism and glycogenesis is converted to fat and stored in fat depots
E. Control of metabolism: primarily by hormones
1. Pancreatic hormones
a. Insulin: exerts predominant control over carbohydrate metabolism but also affects protein and fat
metabolism; in general, it accelerates carbohydrate metabolism by the cells, thereby decreasing blood
glucose
b. Glucagon: primarily accelerates liver glycogenolysis but also promotes gluconeogenesis and lipolysis
when blood insulin levels are low
c. Somatostatin: inhibits the release of insulin and glucagon
2. Anterior pituitary hormones
a. Growth hormone tends to:
(1) Accelerate protein anabolism; hence promotes growth of skeleton and soft tissues
(2) Accelerate fat mobilization from adipose cells, which tends to bring about a shift from the use of
glucose to the use of fats for catabolism
(3) Accelerate liver gluconeogenesis from fats, which tends to increase blood glucose
(4) Stimulate glucagon secretion, which in turn stimulates liver glycogenolysis and glucose release into
the blood
b. ACTH (the adrenocorticotropic hormone): stimulates the secretion of glucocorticoids by the adrenal
cortex
3. Adrenal cortex hormones (glucocorticoids) mainly cortisol and corticosterone, tend to:
a. Accelerate fat mobilization and catabolism, thereby promoting shift to fat catabolism from glucose
catabolism whenever the latter is inadequate for energy needs
b. Accelerate tissue protein mobilization (catabolism)
c. Accelerate liver gluconeogenesis that becomes necessary to maintain blood glucose for nerve cells
when carbohydrate availability is limited
4. Adrenal medulla hormones: epinephrine and norepinephrine (catecholamines) tend to accelerate both
liver and muscle glycogenolysis, with release of glucose from the liver into the circulation; therefore tend
to increase blood sugar
5. Male sex gland hormone: testosterone, secreted by interstitial cells of testes, tends to accelerate
protein anabolism
F. Metabolic rate: calories of heat energy produced and expended per hour or per day
1. Basal metabolic rate (BMR): calories of heat produced when an individual is awake but resting in a
comfortably warm environment 12 to 18 hours after the last meal
a. Factors determining basal metabolic rates
(1) Size: BMR is directly related to square meters of surface area of the body; the larger the surface area,
the higher the BMR
(2) Sex: 5% to 7% higher in males than in females of the same size and age
(3) Age: BMR inversely related to age; as age increases, BMR decreases
(4) Amount of thyroid hormones secreted; thyroid hormones accelerate BMR
(5) Body temperature: BMR directly related to body temperature; 1 oC increase in body temperature above
normal is accompanied by about a 13% increase in BMR
(6) Miscellaneous factors such as sleep (decreases BMR), pregnancy, and emotions (increase BMR)
b. Measurement
(1) Determined by measuring the amount of oxygen inspired in a given time
(2) Reported as normal or as a definite percentage above or below normal
2. Total metabolic rate: calories of heat energy expended per day; equal to basal metabolic rate plus
number of calories of energy used for muscular work, eating and digesting food, and adjusting to cool
temperatures
3. Some principles about the metabolic rate and its relation to body weight
a. For body weight to remain constant (except for variations in water content) the energy balance must be
maintained; body weight remains constant when energy input equals energy output
b. Whenever the energy input (food intake) is greater than the energy output (total metabolic rate), body
weight increases
c. Whenever energy input (food intake) is less than the energy output (total metabolic rate), body weight
decreases
Structures of Gastrointestinal System
Mouth (Buccal Cavity)
A. Lips
B. Cheeks
C. Hard palate: formed by two palatine bones and palatine processes of maxillae
D. Soft palate: formed of muscle in shape of an arch that forms a partition between the mouth and
nasopharynx; fauces (archway) or opening from mouth into oropharynx; uvula, conical-dependent
process; possesses numerous mucus-secreting glands
E. Gums (gingivae)
F. Teeth
1. Deciduous or "baby teeth": 10 in each jaw (20 in set)
2. Permanent: 16 per jaw (32 in set)
3. Eruption
a. Deciduous: first one erupts usually at 6 months of age; rest follow at intervals of 1 or more months;
however, great individual variation in time of eruption of teeth; deciduous teeth are shed between 6 and
13 years of age
b. Permanent: usually between 6 years and about 17 years; third molars (wisdom teeth) last to erupt
G. Tongue
1. Papillae: many rough elevations on surface
2. Taste buds: specialized receptors of cranial nerves VII (facial) and IX (glossopharyngeal); located in
papillae
3. Frenum (or frenulum): fold of mucous membrane that helps anchor tongue to floor of mouth
H. Tonsils: lymphatic tissue connected to the surface epithelium by a channel (crypt); produces
lymphocytes; defense against infection
I. Salivary glands: produce saliva, a mixture of water, mucin, salts, enzyme (salivary amylase)
1. Parotid: below and in front of the ear
2. Submandibular: posterior part of floor of mouth
3. Sublingual: anterior part of floor of mouth, under tongue
Pharynx
Esophagus
A. Location and extent
1. Posterior to trachea; anterior to the vertebral column
2. Extends from the pharynx through an opening in the diaphragm (hiatus) to the stomach
B. Structure: collapsible muscular tube; about 25 cm (10 inches) long
C. Secretions and functions: secretes mucus; facilitates movement of food
Stomach
A. Size, shape, position
1. Size: varies in different persons and according to degree of distention
2. Shape: elongated pouch, with greater curve forming the lower left border
3. Position: in epigastric and left hypochondriac portions of the abdominal cavity
B. Divisions
1. Fundus: the uppermost portion of the stomach; the bulge adjacent to and extending above the
esophageal opening
2. Body: central portion
3. Pylorus: constricted lower portion
C. Curves
1. Lesser: upper right border
2. Greater: lower left border
D. Sphincters
1. Cardiac: guarding opening of the esophagus into the stomach
2. Pyloric: guarding opening of the pylorus into the duodenum
E. Glands of the stomach: secrete gastric juice composed of mucus, hydrochloric acid, and enzymes
1. Simple columnar epithelial cells form the surface of the gastric mucosa; goblet cells secrete mucus
2. Millions of microscopic gastric glands embedded in gastric mucosa composed of different types of
cells; mainly chief cells (zymogenic cells) that secrete gastric juice enzymes, and parietal cells that
secrete hydrochloric acid and intrinsic factor
F. Functions: food storage and liquefaction (chyme)
Small Intestine
A. Size: approximately 2.5 cm (1 inch) in diameter, 6.1 m (20 feet) in length when relaxed
B. Divisions
1. Duodenum: joins pylorus of the stomach; about 25 cm (10 inches) in length; C-shaped
2. Jejunum: middle section about 2.4 m (8 feet) in length
3. Ileum: lower section, about 3.6 m (12 feet) in length; no clear boundary between jejunum and ileum
C. Functions: digestion and absorption
D. Process: mixing movements; peristalsis; secretion of water, ions, and mucus; receives secretions from
the liver, gallbladder, and pancreas
Large Intestine
A. Size: approximately 6.3 cm (2 1/2 inches) in diameter, but only 1.5 m (5 to 6 feet) long when relaxed
B. Divisions
1. Cecum: first 5 to 7.6 cm (2 to 3 inches)
2. Colon
a. Ascending: extends vertically along the right border of the abdomen up to level of the liver
b. Transverse: extends horizontally across the abdomen, below liver and stomach, and above the small
intestine
c. Descending: extends vertically down the left side of the abdomen to level of the iliac crest
d. Sigmoid: S-shaped part of large intestine curving downward below the iliac crest to join the rectum;
lower part of the sigmoid curve that joins rectum bends toward the left
3. Rectum: last 17.7 or 20.3 cm (7 to 8 inches) of intestines
4. Anus: terminal opening of the alimentary tract
C. Functions: water and sodium ion absorption; temporary storage of fecal matter; defecation
D. Process: weak mixing movements, mass movements, and peristalsis
Vermiform Appendix
A. Size, shape, location: about size and shape of a large angleworm; blind-end tube off the cecum just
beyond the ileocecal valve; 7.6 to 10 cm (3 to 4 inches) long; 0.6 cm (1/4 inch) in diameter
B. Structure: same coats as compose the intestinal wall
C. Function: part of the immune system; submucosa unique in the large size of its lymphatic nodules
Liver
A. Location and size: occupies most of the right hypochondrium and part of the epigastrium; largest gland
in the body
B. Lobes: divided into thousands of lobules by blood vessels and fibrous partitions
1. Right lobe: subdivided into two smaller lobes (caudate and quadrate) and right lobe proper
2. Left lobe: single lobe
C. Ducts
1. Hepatic duct: from liver
2. Cystic duct: from gallbladder
3. Common bile duct: formed by union of the hepatic and cystic ducts in a Y formation; drains bile into the
duodenum at the hepatopancreatic papilla, surrounded by the sphincter of Oddi
D. Functions: liver is one of the most vital organs because of its role in metabolism of proteins,
carbohydrates, and fats
1. Carbohydrate metabolism by liver cells
a. Glycogenesis: conversion of glucose to glycogen for storage
b. Glycogenolysis: conversion of glycogen to glucose and release of glucose into the blood; epinephrine
and glucagons accelerate glycogenolysis
c. Gluconeogenesis: formation of glucose from proteins or fats; glucocorticoids (hydrocortisone,
corticosterone) have an accelerating effect on gluconeogenesis
2. Fat metabolism by liver cells
a. Ketogenesis: occurs during accelerated fat catabolism; occurs mainly in liver cells; consists of a series
of reactions by which fatty acids are broken down into molecules of acetyl CoA (beta oxidation), which are
then combined (two at a time) to form ketone bodies (acetoacetic acid, acetone, betahydroxybutyric acid)
b. Fat storage
c. Synthesis of triglycerides, phospholipids, cholesterol, and the B complex factor choline
3. Protein metabolism by liver cells
a. Anabolism: synthesis of various proteins, notably blood proteins (e.g., prothrombin, fibrinogen,
albumins, alpha and beta globulins, and clotting factors V, VII, IX, and X)
b. Deamination: first step in protein catabolism; chemical reaction by which amino group is split off from
amino acid to form ammonia and a keto acid
c. Urea formation: liver cells convert most of the ammonia formed by deamination to urea
4. Secretes bile, substance important for emulsifying fats prior to digestion and as a vehicle for excretion
of cholesterol and bile pigments
5. Detoxifies various substances (e.g., drugs, hormones)
6. Vitamin metabolism: stores vitamins A, D, K, and B 12; synthesizes B3 from tryptophan
Gallbladder
A. Size, shape, location: approximately the size and shape of a small pear; lies on the undersurface of the
liver
B. Structure: sac made of smooth muscle, lined with mucosa arranged in rugae (expandable longitudinal
folds)
C. Functions: concentrates and stores bile
Pancreas
A. Size, shape, location: larger in men than in women, but considerable individual variation; fish shaped,
with body, head, and tail; extends from the duodenal curve to the spleen
B. Structure: that of both a duct gland and a ductless gland
1. Pancreatic cells: pour secretion (pancreatic juice) into the duct that runs length of the gland and
empties into the duodenum at the hepatopancreatic papilla
2. Islets of Langerhans: clusters of cells not connected with pancreatic ducts (two main types of cells
compose islets, namely, alpha and beta cells); constitute the endocrine gland
C. Functions
1. Pancreatic cells connected with pancreatic ducts secrete pancreatic juice, enzymes of which help
digest all three kinds of foods
2. Islet cells constitute endocrine gland
a. Alpha cells secrete the hormone glucagon, which accelerates liver glycogenolysis and initiates
gluconeogenesis; hence, tends to increase blood glucose level
b. Beta cells secrete insulin, one of the most important metabolic hormones, which exerts a profound
influence on the metabolism of carbohydrates, proteins, and fats
(1) Insulin accelerates the active transport of glucose (along with potassium and phosphate ions) through
cell membranes; therefore it tends to decrease blood glucose (hypoglycemic effect) and to increase
glucose utilization by the cells for either catabolism or anabolism
(2) Insulin stimulates the production of liver cell glucokinase; therefore it promotes liver glycogenesis,
another effect that tends to lower blood glucose
(3) Insulin inhibits liver cell phosphatase and therefore inhibits liver glycogenolysis
(4) Insulin accelerates the rate of amino acid transfer into cells, so it promotes anabolism of proteins
within the cells
(5) Insulin accelerates the rate of fatty acid transfer into cells, promotes fat anabolism (also called fat
deposition or lipogenesis), and inhibits fat catabolism
PHARMACOLOGY RELATED TO GASTROINTESTINAL
SYSTEM DISORDERS
Antiemetics
A. Description
1. Used to alleviate nausea and vomiting
2. Act by:
a. Diminishing the sensitivity of the chemoreceptor trigger zone (CTZ) to irritants or
b. Decreasing labyrinthine excitability
3. Effective in the prevention and control of emesis and motion sickness
4. Available in oral, parenteral (IM, IV), rectal, and transdermal preparations
B. Examples
1. Centrally acting agents
a. Benzquinamide (Emete-con)
b. Ondansetron HCl (Zofran)
c. Prochlorperazine (Compazine)
d. Trimethobenzamide HCl (Tigan)
2. Agents for motion sickness control
a. Dimenhydrinate (Dramamine)
b. Meclizine HCl (Antivert, Bonine)
c. Promethazine HCl (Phenergan)
d. Thiethylperazine maleate (Torecan)
3. Agents that promote gastric emptying
a. Cisapride (Propulsid)
b. Metoclopramide (Reglan)
C. Major side effects
1. Drowsiness (CNS depression)
2. Hypotension (vasodilation via central mechanism)
3. Dry mouth (decreased salivation from anticholinergic effect)
4. Blurred vision (pupillary dilation from anticholinergic effect)
5. Incoordination (an extrapyramidal symptom due to dopamine antagonism)
D. Nursing care
1. Observe occurrence and characteristics of vomitus
2. Eliminate noxious substances from the diet and environment
3. Provide good oral hygiene
4. Caution client to avoid engaging in hazardous activities during therapy
5. Offer sugar-free chewing gum or hard candy to promote salivation
6. Instruct client to change positions slowly
7. Evaluate client's response to medication and understanding of teaching
Anorexiants
A. Description
1. Used to suppress the appetite
2. Act at the hypothalamic appetite centers to suppress the desire for food; they
generally produce CNS stimulation
3. Available in oral preparations
B. Examples
1. Amphetamine sulfate (Benzedrine)
2. Benzphetamine HCl (Didrex)
3. Dextroamphetamine sulfate (Dexedrine)
4. Fenfluramine HCl (Pondimin)
5. Phenmetrazine HCl (Preludin)
C. Major side effects
1. Nausea, vomiting (irritation of gastric mucosa)
2. Constipation (delayed passage of stool in GI tract)
3. Tachycardia (sympathetic stimulation)
4. CNS stimulation (sympathetic activation)
5. Fenfluramine: CNS depression (direct effect)
D. Nursing care
1. Educate client regarding:
a. Drug misuse (controlled substances)
b. Concurrent exercise and diet therapy
c. Need for medical supervision during therapy
d. Possibility of affecting ability to engage in hazardous activities
2. Fenfluramine: assess for history of depression, alcohol abuse, or suicidal tendencies;
avoid administration in these situations
3. Evaluate client's response to medication and understanding of teaching
Antacids
A. Description
1. Used to neutralize gastric acid
2. Act by providing a protective coating on the stomach lining and lowering the gastric
acid level, which allows more rapid movement of stomach contents into the duodenum
3. Effective in the treatment of ulcers
4. Available in oral preparations
B. Examples
1. Aluminum carbonate gel (Basaljel)
2. Aluminum hydroxide gel (Amphojel)
3. Aluminum hydroxide with magnesium trisilicate (Gelusil)
4. Aluminum and magnesium hydroxides (Maalox)
5. Aluminum phosphate gel (Phosphaljel)
6. Magaldrate (Riopan)
7. Sodium bicarbonate: systemic antacid; may cause alkalosis
C. Major side effects
1. Constipation (aluminum compounds) (aluminum delays passage of stool in GI tract)
2. Diarrhea (magnesium compounds) (magnesium stimulates peristalsis in GI tract)
3. Alkalosis (systemic antacids) (absorption of alkaline compound into the circulation)
4. Reduced absorption of calcium and iron (increase in gastric pH)
D. Nursing care
1. Instruct the client regarding:
a. Prevention of overuse of antacids which can result in rebound hyperacidity
b. Need for continued supervision
c. Dietary restrictions related to gastric distress
d. Encouraging foods high in calcium and iron
2. Caution client on a sodium-restricted diet that many antacids contain sodium
3. Shake oral suspensions well prior to administration
4. Administer with small amount of water to ensure passage to stomach
5. Evaluate client's response to medication and understanding of teaching
Gastrointestinal Anticholinergics
A. Description
1. Used to alleviate pain associated with peptic ulcer
2. Act by inhibiting smooth muscle contraction in the GI tract
3. Available in oral and parenteral (IM, SC, IV) preparations
B. Examples
1. Atropine sulfate
2. Belladonna leaf, tincture
3. Dicyclomine HCl (Bentyl)
4. Glycopyrrolate (Robinul)
5. Methantheline bromide (Banthine)
6. Propantheline bromide (Pro-Banthine)
C. Major side effects (all related to decreased parasympathetic stimulation)
1. Abdominal distention (decreased peristalsis)
2. Constipation (decreased peristalsis)
3. Dry mouth (decreased salivation)
4. Urinary retention (decreased parasympathetic stimulation)
5. CNS disturbances (direct CNS toxic effect)
D. Nursing care
1. Provide dietary counseling with emphasis on bland foods
2. Offer sugar-free chewing gum or hard candy to promote salivation
3. Evaluate client's response to medication and understanding of teaching
Gastrointestinal Antihistamines
A. Description
1. Used to inhibit gastric acid secretion
2. Act at the H2 receptors of the stomach parietal cells
3. Effective in the short-term therapy of peptic ulcer
4. Available in oral and parenteral (IM, IV) preparations
B. Examples
1. Cimetidine (Tagamet)
2. Famotidine (Pepcid)
3. Nizatidine (Axid)
4. Omeprazole (Prilosec)
5. Ranitidine (Zantac)
C. Major side effects
1. CNS disturbances (decreased metabolism of drug because of liver or kidney
impairment)
2. Blood dyscrasias (decreased RBCs, WBCs, platelet synthesis)
3. Skin rash (hypersensitivity)
4. Reduced calcium and iron absorption (increase in gastric pH)
D. Nursing care
1. Do not administer at same time as antacids; allow 1 to 2 hours between drugs
2. Administer oral preparations with meals
3. Assess for potentiation of oral anticoagulant effect
4. Instruct client regarding dietary restrictions; also encourage foods high in calcium and
iron
5. Instruct client to follow prescription exactly; Prilosec administration should not exceed
8 weeks
6. Evaluate client's response to medication and understanding of teaching
Antidiarrheals
A. Description
1. Used to alleviate diarrhea
2. Act by various mechanisms to promote the formation of a formed stool
3. Available in oral and parenteral (IM) preparations
B. Examples
1. Fluid adsorbents: decrease the fluid content of stool
a. Bismuth subcarbonate
b. Kaolin and pectin (Kaopectate)
2. Enteric bacteria replacements: enhance production of lactic acid from carbohydrates
in the intestinal lumen; acidity suppresses pathogenic bacterial overgrowth
a. Lactobacillus acidophilus (Bacid)
b. Lactobacillus bulgaricus (Lactinex)
3. Motility suppressants: decrease GI tract motility so that more water will be absorbed
from the large intestine
a. Diphenoxylate HCl (Lomotil)
b. Tincture of opium (paregoric)
c. Loperamide HCl (Imodium)
C. Major side effects
1. Fluid adsorbents
a. GI disturbances (local effect)
b. CNS disturbances (direct CNS toxic effect)
2. Enteric bacteria replacements
a. Excessive flatulence (increased microbial gas production)
b. Abdominal cramps (increased microbial gas production)
3. Motility suppressants
a. Urinary retention (decreased parasympathetic stimulation)
b. Tachycardia (vagolytic effect on cardiac conduction)
c. Dry mouth (decreased salivation from anticholinergic effect)
d. Sedation (CNS depression)
e. Paralytic ileus (decreased peristalsis)
f. Respiratory depression (depression of medullary respiratory center)
D. Nursing care
1. Monitor bowel movements (BMs) for color, characteristics, and frequency
2. Assess for fluid/electrolyte imbalance
3. Assess and eliminate cause of diarrhea
4. Motility suppressants
a. Warn client of risk of physical dependence with long-term use
b. Offer sugar-free chewing gum and hard candy to promote salivation
c. May interfere with ability to perform hazardous activities
5. Evaluate client's response to medication and understanding of teaching
Cathartics/Laxatives
A. Description
1. Used to alleviate or prevent constipation
2. Act by various mechanisms to promote evacuation of a normal stool
3. Available in oral and rectal preparations
B. Examples
1. Intestinal lubricants: decrease dehydration of feces; lubricate intestinal tract
a. Mineral oil
b. Olive oil
2. Fecal softeners: lower surface tension of feces in colon; allow water and fats to
penetrate feces
a. Dioctyl calcium sulfosuccinate (Surfak)
b. Dioctyl sodium sulfosuccinate (Colace)
3. Bulk-forming laxatives: increase bulk in intestinal lumen, which stimulates propulsive
movements by pressure on mucosal lining
a. Methylcellulose (Cellothyl)
b. Psyllium hydrophilic mucilloid (Metamucil)
4. Colon irritants: stimulate peristalsis by reflexive response to irritation of intestinal
lumen
a. Bisacodyl (Dulcolax)
b. Cascara sagrada (Peristim)
c. Castor oil
d. Senna (Senokot)
5. Saline cathartics: increase osmotic pressure within intestine, drawing fluid from blood
and bowel wall, thus increasing bulk and stimulating peristalsis
a. Effervescent sodium phosphate (Fleet Phospho-Soda)
b. Magnesium citrate solution
c. Magnesium sulfate (Epsom salts)
d. Milk of magnesia
C. Major side effects
1. Laxative dependence with long-term use (loss of normal defecation mechanism)
2. GI disturbances (local effect)
3. Intestinal lubricants
a. Inhibited absorption of fat-soluble vitamins (coat the GI mucosa prohibiting absorption
of vitamins A, D, E, K)
b. Anal leaking of oil (accumulation of lubricant near rectal sphincter)
4. Saline cathartics
a. Dehydration (fluid volume depletion due to hypertonic state in GI tract)
b. Hypernatremia (increased sodium absorption into circulation; loss of some fluid from
vasculature)
D. Nursing care
1. Instruct the client regarding:
a. Overuse of cathartics and intestinal lubricants
b. Increasing intake of fluids and dietary fiber
c. Increasing activity level
d. Compliance with bowel-retraining program
2. Monitor BMs for consistency and frequency of stool
3. Intestinal lubricants: utilize peripad to protect clothing
4. Bulk-forming laxatives: mix thoroughly in 8 oz of fluid and follow with another 8 oz of
fluid to prevent obstruction
5. Administer at bedtime to promote defecation in the morning
6. Evaluate client's response to medication and understanding of teaching

Pancreatic Enzymes
A. Description
1. Used to promote the digestion of proteins, fats, and starches
2. Act as replacements for natural endogenous pancreatic enzymes (protease, lipase,
amylase)
3. Available in oral preparations
B. Examples
1. Pancreatin (Viokase)
2. Pancrelipase (Cotazym)
C. Major side effects
1. Nausea (GI irritation)
2. Diarrhea (GI irritation)
D. Nursing care
1. Administer with meals; teach client to take with meals
2. Avoid crushing preparations that are enteric coated
3. Provide a balanced diet to prevent indigestion
4. Evaluate client's response to medication and understanding of teaching
PROCEDURES RELATED TO THE GASTROINTESTINAL
SYSTEM
Barium Enema
A. Definition: introduction of barium, an opaque medium, into the intestines for the purpose of x-ray
visualization for pathologic changes
B. Nursing care
1. Explain procedure to the client
2. Prepare the client for the procedure by:
a. Administering cathartics and/or enemas as ordered to evacuate the bowel
b. Maintaining the client NPO for 8 to 10 hours prior to the test
3. Inspect stool after the procedure for the presence of barium
4. Administer enemas and/or cathartics as ordered if the stool does not return to normal
5. Encourage fluid intake
6. Evaluate client's response to procedure
Colostomy Irrigation and Care
A. Definition
1. Instillation of fluid into the lower colon via a stoma on the abdominal wall to stimulate peristalsis and
facilitate the expulsion of feces
2. Cleansing the colostomy stoma and collection of feces (stool consistency will depend on location of the
ostomy: a colostomy of the sigmoid colon will tend to produce formed stools; a transverse or ascending
colostomy will produce less formed stools)
B. Nursing care
1. Secure a physician's order
2. Irrigate the stoma at the same time each day to approximate normal bowel habits
3. Insert a well-lubricated catheter tip into the stoma approximately 7 to 10 cm in the direction of the
remaining bowel (anatomy of ascending, transverse, and descending colon should be considered); as the
solution is allowed to flow, the catheter may be advanced
4. Hold the irrigating container 30.5 to 45.7 cm (12 to 18 inches) above the colostomy; irrigating solution
should be 105o F (40.5o C)
5. Clamp tubing or temporarily lower the container if the client complains of cramping
6. Provide privacy while waiting for fecal returns or permit the client to ambulate with the collection bag in
place to further stimulate peristalsis
7. Cleanse the stoma; if excoriation occurs, a soothing ointment may be ordered
8. Apply a colostomy bag or gauze dressing (if the colostomy is well regulated)
9. Teach the client to control odor when necessary by placing two aspirin tablets (or commercially
available deodorizers) in the colostomy bag or by taking bismuth subcarbonate tablets orally to control
odor
10. Evaluate client's response to procedure
Endoscopy
A. Definition: visualization of the esophagus, stomach, gallbladder, pancreas, colon, or rectum using a
hollow tube with a lighted end
1. Gastroscopy: stomach
2. Esophagoscopy: esophagus
3. Sigmoidoscopy: sigmoid colon
4. Proctoscopy: rectum
5. Endoscopic retrograde cholangiopancreatography (ERCP)
B. Nursing care
1. Obtain an informed consent for the procedure
2. If rectal examination is indicated, administer cleansing enemas prior to the test
3. Restrict diet (NPO) prior to procedure
4. Following the procedure, observe for bleeding, changes in vital signs, or nausea
5. If the throat is anesthetized (as for a gastroscopy or esophagoscopy), check for the return of gag reflex
before offering oral fluids
6. Evaluate client's response to procedure
Enemas
A. Definitions
1. Tap-water enema (TWE): introduction of water into the colon to stimulate evacuation
2. Soapsuds enema (SSE): introduction of soapy water into the colon to stimulate peristalsis by bowel
irritation; contraindicated as a preparation for an endoscopic procedure because it may
alter the appearance of the mucosa
3. Hypertonic enema: commercially prepared small-volume enema that works on the principle of osmosis
4. Harris flush or drip: introduction of water into the colon as tolerated and subsequent repeated drainage
of that water through the same tubing to facilitate passage of flatus
5. High colonic irrigation: introduction of water into the upper portion of the colon to facilitate complete
fecal evacuation
6. Instillation: introduction of a liquid (usually mineral oil) into the colon to facilitate fecal activity through
lubricating effect
B. Nursing care
1. Explain procedure to client
2. Provide privacy; place in side-lying position
3. Obtain the correct solution
4. Lubricate the tip of a rectal catheter with water-soluble jelly
5. Insert the catheter 10 to 15 cm (4 to 6 inches) into the rectum
6. Allow the solution to enter slowly; keep it no more than 30.5 to 45.7 cm (12 to 18 inches) above the
rectum; temporarily interrupt flow if cramps occur
7. Allow ample time for the client to expel the enema
8. Observe and record the amount and consistency of returns
9. Evaluate client's response to procedure
Gastric Analysis
A. Definition
1. Analysis of stomach contents for the presence of abnormal constituents or lack of normal constituents
such as hydrochloric acid, blood, acid-fast bacteria, and lactic acid
2. Acid content is elevated in ulcers, decreased in malignant conditions of the stomach, and absent in
pernicious anemia
B. Nursing care
1. Explain procedure to client
2. Maintain the client NPO prior to the test and have a nasogastric tube passed at time of procedure
3. Administer histamine or caffeine to stimulate hydrochloric acid secretion prior to the procedure if
ordered
4. Obtain stomach contents, secure in an appropriate container, and send to laboratory
5. Evaluate client's response to procedure
Gastrointestinal (GI) Series
A. Definition: introduction of barium, an opaque medium, into the upper GI tract via the mouth,
gastrostomy tube, or nasogastric tube to visualize the area by x-ray methods
B. Nursing care
1. Explain procedure to client
2. Maintain the client NPO after midnight
3. Inform client that the stool will be white or pink for 24 to 72 hours after procedure
4. Encourage fluids and administer cathartics as ordered
5. Evaluate client's response to procedure
Gavage (Tube Feeding)
A. Definitions
1. Nasogastric
a. Placement of a tube through the nose into the stomach, securing it in place with tape
b. Prepared nutritional supplements are introduced through this tube
2. Intestinal
a. Placement of a tube through the nose into the small intestine, securing it in place with tape
b. There is less likelihood of aspiration because the pyloric sphincter inhibits backflow
3. Surgically placed feeding tubes
a. Cervical esophagostomy: tube is sutured directly into the esophagus for clients who have had head
and neck surgery
b. Gastrostomy: tube is placed directly into stomach through the abdominal wall and sutured in place;
used for clients who require tube feeding on a long-term basis
c. Jejunostomy: tube is inserted directly into the jejunum for clients with pathologic conditions of the upper
GI tract
4. Percutaneous endoscopic gastrostomy (PEG)
a. Stomach is punctured during endoscopy procedure
b. Does not require general anesthesia or laparotomy
c. Dressing should be changed daily
d. Although associated with reduced risks, accidental removal and aspiration still may occur
B. Nursing care
1. Verify placement of tube prior to feeding
a. Inject a small amount of air into the tube and, with a stethoscope placed over the epigastric area, listen
for the passage of air into the stomach
b. Aspirate for presence of stomach contents; reinstill to avoid electrolyte imbalance
c. Test aspirate for acid pH
d. Small-bore tube placement must be verified by x-ray examination
2. Aspirate contents of stomach prior to feeding to determine residual; reinstill to avoid electrolyte
imbalance; withhold feeding if the residual is greater than 150 ml
3. Intermittent feeding
a. Position the client so that the head is elevated during and for 1 hour after the feeding
b. Appropriately verify placement of tube
c. Introduce a small amount of water (30 ml) first to verify the patency of the tube; the tube should not be
allowed to empty during feeding so that excess air is not forced into the stomach
d. Slowly administer the feeding at room or body temperature; observe and question the client to
determine tolerance; the higher the feeding container and the larger the lumen of the feeding tube, the
more rapid the flow
e. Administer a small amount of water to clear the tube at the completion of the feeding
f. Clamp the tubing and clean the equipment
g. Place client in sitting position for 1 hour after feeding; place infant in right side-lying position
4. Continuous feeding
a. Place prescribed feeding in gavage bag and prime tubing to prevent excess air from entering stomach
b. Set rate of flow; rate of flow can be manually regulated by setting drops per minute or mechanically
regulated by using an electric pump
c. Position the client to keep the head elevated throughout the feeding
d. Appropriately verify placement of tube when adding additional fluid to a continuous feeding
e. Flush tube intermittently with water to prevent occlusion of tube with feeding
f. Monitor for gastric distention and aspiration; since smaller amounts of feeding are generally
administered within a given period, gastric distention and subsequent aspiration are less frequent
g. Discard unused fluid that has been in gavage administration bag at room temperature for longer than 4
hours
5. Care common for all clients receiving tube feedings
a. Monitor for abdominal distention; changes in bowel sounds or diarrhea
b. Discontinue feeding if nausea and/or vomiting occur
c. Provide oral hygiene
d. When appropriate, encourage the client to chew foods that will stimulate gastric secretions while
providing psychologic comfort; chewed food may not be swallowed
e. Provide special skin care; if the client has a gastrostomy tube sutured in place, the skin may become
irritated from gastrointestinal enzymes; if the client has a nasogastric tube, the skin may become
excoriated at point of entry because of irritation
f. Evaluate client's response to the procedure
Ileostomy Care
A. Definition: physical care of the ileostomy stoma and surrounding skin
B. Nursing care
1. Protect the skin from irritation, since the feces will be liquid because of the anatomic location of the
stoma
2. Explain procedure to the client and family and encourage selfcare
3. Do not irrigate the stoma
4. Affix an appliance with an adequate seal (e.g., karaya) to prevent accidental leakage around the stoma;
the appliance is generally changed every 2 to 4 days but emptied every 6 hours
5. Evaluate client's response to procedure
Irrigation of Nasogastric (Levin) Tube
A. Definition
1. The Levin tube is commonly used for gastric decompression
2. Purposes of insertion of a nasogastric tube include emptying the stomach, obtaining a specimen for
diagnostic purposes, or providing a means for nourishment
3. Irrigation is the insertion and then removal of fluid (usually normal saline) to maintain patency
B. Nursing care
1. Check that the order for irrigations has been written by the physician
2. Ascertain the patency of the Levin tube attached to intermittent suction by observing for drainage;
nausea or abdominal discomfort may indicate that the tube is occluded
3. Assemble equipment: 30-ml syringe or bulb syringe, irrigating solution, and basin for returning fluid
4. Verify placement
5. Instill approximately 30 ml of fluid into the tube
6. Gently withdraw the same volume of fluid as was instilled; if the client has undergone gastric surgery,
the physician will generally order instillations; in this case, irrigation fluid is instilled but not withdrawn; the
amount instilled must be subtracted from total gastric output
7. Chart the amount, color, and consistency of drainage
8. Evaluate client's response to procedure
Paracentesis
A. Definition: surgical puncture of the peritoneal membrane of the abdominal cavity for the purpose of
removing fluid
B. Nursing care
1. Explain the procedure; obtain consent
2. Have the client void prior to procedure to avoid accidental trauma to the bladder
3. Assist the client to a sitting position
4. Observe for signs of shock; sudden fluid shifts can result in hypotension
5. Chart the amount and characteristics of fluid withdrawn
6. Apply a dry sterile dressing to the puncture site
7. Properly label the specimen if required and send to the laboratory
8. Evaluate client's response to the procedure
Parenteral Replacement Therapy
A. Definitions
1. Peripheral parenteral nutrition (PPN)
a. Administration of isotonic lipid and amino acid solutions through a peripheral vein
b. Amino acid content should not exceed 4%; dextrose content should not be greater than 10%
c. Assists in maintaining a positive nitrogen balance
2. Total parenteral nutrition (TPN)
a. Administration of carbohydrates, amino acids, vitamins, and minerals via a central vein (usually the
superior vena cava)
b. High osmolality solutions (25% dextrose) are administered in conjunction with 5% to 10% amino acids,
electrolytes, minerals, and vitamins
c. Assists in maintaining a positive nitrogen balance
3. Intralipid therapy
a. Infusion of 10% to 20% fat emulsion that provides essential fatty acids
b. Provides increased caloric intake to maintain positive nitrogen balance
4. Total nutrient admixture (TNA or "3 in 1")
a. Combination of dextrose, amino acids and lipids in one container; vitamins and minerals may be added
b. Administered through a central line over 24 hours
B. Nursing care
1. Infuse fluid through a large vein such as the subclavian because of the high osmolarity of the solution
used in TPN
2. Ensure proper placement of the tube by chest x-ray examination after insertion of a catheter; accidental
pneumothorax can occur during insertion
3. Precisely regulate the fluid infusion rate; an intravenous pump should be used if available
a. Rapid infusion may result in movement of the fluid into the intravascular compartment; dehydration,
circulatory overload, and hyperglycemia can occur
b. Slow infusion may result in hypoglycemia, since the body adapts to the high osmolarity of this fluid by
secreting more insulin; for this reason, therapy is never terminated abruptly but is gradually discontinued
4. Use aseptic technique when handling the infusion or changing the dressing (in many institutions, only
nurses specially prepared are allowed to change the dressing because of the high risk of infection)
5. Consult manufacturer's instructions about tubing when administering lipids
6. Utilize a filter for TPN; filters cannot be used for lipids
7. Use surgically aseptic technique when changing tubing
8. Record daily weights, and monitor urinary sugar and acetone or blood glucose levels frequently
9. Check laboratory reports daily, especially glucose, creatine, BUN, and electrolytes; serum lipids and
liver function studies if lipids are administered
10. Monitor temperature every four hours since infection is the most common complication of TPN; if the
client has a temperature elevation, order cultures of blood, urine, and sputum to rule out other sources of
infection
11. Evaluate client's response to procedure
Stool Specimens
A. Definitions
1. Stool for guaiac (occult blood): specimen or smear of stool on a commercially prepared card is
analyzed for the presence of blood); positive results indicate the presence of blood in the stool and may
suggest diverse diseases such as peptic ulcer, gastritis, gastric or colonic carcinoma, colitis, or
diverticulitis
2. Stools for O and P (ova and parasites): must be sent to the laboratory while still warm for microscopic
examination unless a preservative is available
3. Stool culture: specimen or swab of stool is sent in a sterile container for identification of abnormal
bacterial growth
B. Nursing care
1. Explain procedure to the client
2. Collect specimen in an appropriate container
3. Label the container with the client's name, identification/hospital number, physician, and room number
4. Chart that the specimen was sent and any unusual assessment of the stool

GENERAL NURSING DIAGNOSES FOR CLIENTS WITH

GASTROINTESTINAL SYSTEM DISORDERS
A. Activity intolerance related to malaise
B. Anxiety related to:
1. Prognosis
2. Pain
C. Risk for aspiration related to:
1. Interference with swallowing
2. Wired jaws
3. Gastrointestinal tube feedings
D. Body image disturbance related to:
1. Disease process (fluid retention or malnutrition)
2. Alterations in structure or function because of surgical intervention
E. Bowel incontinence related to impaired sphincter control
F. Colonic constipation related to less than adequate fiber/fluid intake
G. Constipation related to:
1. Dietary habits
2. Inadequate intake of fluids
3. Inactivity
4. Obstruction
5. Fear of pain when defecating
6. Absence of motility
H. Diarrhea related to:
1. Local inflammatory process
2. Anxiety
3. Food intolerance
4. Contaminated foods
I. Risk for fluid volume deficit related to:
1. Hypovolemia
2. Increased intestinal motility
J. Fluid volume excess related to ascites
K. Risk for infection related to altered mucous membranes
L. Risk for injury related to:
1. Hemorrhage
2. Metastasis
3. Strangulation
4. Sensory/perceptual alterations
M. Ineffective management of therapeutic regimen (families) related to:
1. Complexity of therapeutic regimen
2. Feelings concerning secretions and/or excretions
N. Ineffective management of therapeutic regimen (individual) related to:
1. Complexity of therapeutic regimen
2. Feelings concerning secretions and/or excretions
O. Altered nutrition: less than body requirements related to:
1. Anorexia
2. Inability to ingest
3. Malabsorption
4. Changes in metabolism
5. Therapeutic nothing-by-mouth status
6. Nausea
P. Altered nutrition: risk for more than body requirements related to excess ingestion
Q. Altered oral mucous membrane related to chemical and/or microbiologic irritants
R. Pain related to:
1. Pathologic processes
2. Diagnostic procedures
3. Therapeutic modalities
S. Impaired skin integrity related to:
1. Pruritis
2. Irritation by intestinal drainage
T. Social isolation related to:
1. Disfiguring surgery
2. Risk of transmission
U. Impaired swallowing related to obstruction in oropharyngeal and/or esophageal structures
V. Risk for trauma related to mechanical devices used for irrigation