GASTROINTESTINAL SYSTEM

-BASIC CONCEPTS OF NUTRITION

-NUTRITIONAL NEEDS

-INTESTINAL ELIMINATION

OBJECTIVES

Syllabus page 39-41

PRETEST

1. Name 1 fat-soluble vitamin 2. Name 1 water-soluble vitamin 3. How often should a nasogastric tube

be changed on a client? 4. Identify 1 type of enema 5. Define effluence

ANSWERS

1. K, A, D, E 2. C, vitamin B-complex: folic acid,

niacin, thiamine, riboflavin, pyridoxine, cobalamin

3. PRN and per agency policy 4. Hypertonic, hypotonic, isotonic, soap,

oil 5. Product or drainage from an ostomy

WHAT IS NUTRITION?

Nutrition is the sum of all the interactions between an organism and the food it consumes

It is what a person eats & how the body uses it

WHAT ARE NUTRIENTS?

Nutrients are the organic & inorganic substances found in foods & required for body functioning

Essential nutrients in food are needed for growth & maintenance of all body tissues & the normal functioning of all body processes

WHAT ARE THE ESSENTIAL NUTRIENTS? (6) 1. Water 2. Carbohydrates (CHO) 3. Proteins 4. Fats 5. Vitamins 6. Minerals

WHAT ARE THE FUNCTIONS OF NUTRIENTS? (3) 1. Providing energy for body process &

movement 2. Providing structural material for body

tissues 3. Regulating body processes

WHAT DOES NUTRITIVE VALUE MEAN? It is the nutrient content of a specified

amount of food No one food provides all essential

nutrients

WHAT DOES CALORIC VALUE MEAN? It is the amount of energy that nutrients

or foods supply to the body

WHAT IS A CALORIE?

A calorie is the amount of heat required to raise the temperature of 1 gram of water 1 degree C

1 gm of CHO =4 kcal (after metabolization) 1 gm of protein = 4 kcal (after

metabolization) 1 gm of fat= 9 kcal after (metabolization)

WHAT DOES NUTRIENT DENSITY MEAN? It refers to foods that deliver the most

nutrient for the lowest kilocalorie Nutrient-dense food provides a high

quantity of 1 or more essential nutrients with a small quantity of kilocalories

eg: 1 baked potato + butter= 260 KCAL 3oz sirloin = 240 KCAL

WHAT IS METABOLISM?

Metabolism refers to all biochemical & physiologic processes by which the body grows and maintains itself

It is normally expressed in terms of the rate of heat liberated during these chemical reactions

WHAT IS BASAL METABOLIC RATE? (BMR) It is the rate at which the body

metabolizes food to maintain the energy requirements of a person who is awake and at rest

the energy in food maintains the basal metabolic rate of the body & provides energy for activities

WHAT FACTORS AFFECT CALORIC NEEDS? (8) 1. Age 2. Growth 3. Gender 4. Climate 5. Sleep 6. Activity 7. Fever 8. Illness

WHAT IS THE BODY’S MOST BASIC NUTRIENT?

WATER

WHAT ARE MACRONUTRIENTS? These are energy-providing nutrients

(3)= carbohydrates (CHO), fats, and proteins

Hunger impels people to eat enough of these to meet their energy needs

WHAT ARE MICRONUTRIENTS? These are vitamins and minerals which

are needed by the body

WHAT ARE CARBOHYDRATES COMPOSED OF? 3 elements: Carbon (C), hydrogen (H),

and oxygen (O); abbreviated CHO There are 2 basic kinds: Simple CHO

(sugars) and complex CHO (starches and fiber)

WHAT IS A SUGAR?

A sugar is the simplest of all CHO It is water soluble it is produced naturally by both plants &

animals There are monosaccharides (single

molecules) and Disaccharides ( double molecules)

WHAT ARE THE 3 MONOSACCHARIDES? 1. Glucose; this one is the most

abundant 2. Fructose 3. Galactose Examples of foods containing sugars are

sugar cane, fruits, lactose and processed sugars such as cookies, candy, ice cream

WHAT IS A STARCH?

A starch is an insoluble, nonsweet form of CHO

They are polysaccharides = composed of branched chains of dozens or hundreds of glucose molecules

Nearly all starches exist naturally in plants, such as grains, legumes & potatoes

They are processed as cereals, etc.

WHAT IS FIBER?

It is a complex CHO derived from plants Cannot be digested by humans;

supplies roughage Bulk satisfies appetite & helps the

digestive tract to function effectively to eliminate wastes

WHAT ARE OTHER FUNCTIONS OF CHO? 1. Supply vital nutrients: protein,

vitamins, minerals, & dietary fiber that are not found in processed foods

2. Refined CHO foods are relatively low in nutrients in relation to the large number of calories they contain= “empty calories”

WHAT IS A PROTEIN?

It is an organic substance composed of amino acids

Contain carbon, hydrogen , oxygen & nitrogen

Every cell in the body contains some protein

3/4 of body solids are proteins

WHAT ARE THE TYPES OF AMINO ACIDS? 1. Essential amino acids- cannot be

manufactured by body & must be supplied through protein ingested in diet; 9 essential amino acids necessary for tissue growth & maintenance

2. Nonessential amino acids= body can manufacture by taking apart amino acids derived from diet & reconstructing new ones

WHAT ARE THE TYPES OF PROTEIN? (4) 1. Complete proteins= contain all

essential amino acids + many nonessential ones; eg.: most animal proteins like meats, poultry, fish, dairy products & eggs

2. Partially complete proteins=contain less than the required amt. of 1 or more essential amino acids; cannot alone support growth e.g. milk protein casein

(CON’t)

3. Incomplete proteins= lack 1 or more essential amino acids; are usually derived from vegetables; if an appropriate mixture of plant proteins is provided in diet, a balanced ration of essential amino acids can be achieved

4. Complementary proteins= combinations of 2 or more vegetables

WHAT IS THE FUNCTION OF PROTEIN? Protein is essential in building,

maintaining & repairing body tissue

WHAT DOES PROTEIN METABOLISM CONSIST OF? 1. Anabolism= building tissue 2. Catabolism= breaking down tissue 3. Balance

WHAT IS NITROGEN BALANCE? Measure of the degree of protein

anabolism & catabolism it is the net result of intake and loss of

nitrogen Nitrogen intake should equal nitrogen

output= Nitrogen balance; this is the normal state of healthy people

WHEN DOES POSITIVE NITROGEN EXIST? 1. During periods of growth= childhood

& adolescence, pregnancy, phases of physical exercise

2. During periods of tissue replacement= convalescence from protein-depleting illness and after fasting or inadequate intake of protein & calories when body tissues are regenerated

WHEN DOES -NITROGEN BALANCE EXIST? 1. Pt. does not consume adequate

essential amino acids &/or calories 2. Pt. is inmobilized 3. Pt. is exposed to unusual stress as a

result of trauma

WHAT IS A LIPID?

Lipids are organic substances that are greasy and insoluble in H2O but soluble in ETOH or ether

Fats are lipids that are solid at room temp.

Oils are lipids that are liquid at room temp

WHAT IS AN UNSATURATED FATTY ACID? It is a fatty acid that could accommodate

more H atoms than it currently does; e.g.: vegetable oil

These products are usually liquid at room temp.

WHAT ARE FUNCTIONS OF FATS? 1. Energy metabolism 2. Skin/hair (shine);provides structure 3. Provides insulation ( insulates body

from extreme temp) 4. Provides protection of vital organs 5. Transportation of fat soluble vitamins

(KADE) 6. Adds flavor to food

WHAT IS CHOLESTEROL?

It is a lipid that is both produced by the body and found in foods of animal origin

Most of the body’s cholesterol is synthesized in the liver

Some is absorbed from the diet eg: milk, egg yolk, & organ meats

WHAT ARE FUNCTIONS OF CHOLESTEROL? Important component of cell membrane Abundant in brain & nerve cells Used to synthesize bile acids Is a precursor of steroid hormones &

vitamin D High levels = ^ risk of ASHD; < by eating

less total fat (saturated fat ) & ^ fiber intake to increase fecal excretion of cholesterol

WHAT ARE FOOD SOURCES OF CHOLESTEROL? Egg Yolks Shell fish organ meats Dairy fats

WHAT ARE THE MICRONUTRIENTS? 1. Vitamins 2. Minerals

WHAT IS A VITAMIN?

It is an organic compound that cannot b manufactured by the body & is need in small quantities to catalyze metabolic processes

When vitamins are lacking in the diet, metabolic deficits result

WHAT ARE THE TYPES OF VITAMINS? 1. Water soluble= C and B-complex

(B1, B2, B3, B6, B9, B 12 Pantothenic acid & biotin)

2. Fat soluble vitamins= K, A, D, & E

FAT SOLUBLE VITAMINS

Dissolve in fatty tissue Not destroyed by ordinary cooking

methods Absorbed with fats from intestines Soluble in fat

WATER SOLUBLE VITAMINS

Dissolve in H2O Easily absorbed in small intestine then

passed into blood stream Not stored in body Must be taken daily

WHAT IS A SATURATED FATTY ACID? It is a fatty acid in which all C atoms are

filled to capacity with H; e.g.: butter These products are usually solid at

room temp.

WHAT IS A MINERAL?

It is found in organic compounds as free ions

there are 2 categories of minerals= macrominerals = those required daily in amts. over 100mg

microminerals = those required daily in amounts less than 100 mg

WHAT ARE THE MINERALS?

Macro minerals: Calcium, Potassium, Chloride, Phosphorus

Micro minerals; Iron, and Zinc

WHAT ARE RECOMMENDED DIETARY ALLOWANCES? RDA = standards list published by

Committee on Dietary Allowances of the Food and Nutrition Board of the National Academy of Sciences

RDAs= levels of intake in gms and mgs of essential nutrients that adequately meet the known nutritional needs of most healthy people; most appropriate for pros.

(con’t)

RDAs nutrient levels are high enough to meet the needs of 97.5% of people in the group & to allow some loss of nutrient as it makes its way through the body

the effect of illness or injury & the variability among individuals within any given subgroup are not taken into account in the RDAs

WHAT ARE DIETARY GUIDELINES? These guides were developed to help

healthy people meet the daily requirements of essential nutrients & to facilitate meal planning e.g.:

The Food Guide Pyramid Dietary Guidelines for Americans

BASIC FOUR FOOD GUIDE

Based on 4 basic food groups: 1. Milk & milk products 2. Meats & alternatives 3. Breads & cereals 4. Fruits & vegetables Introduced by USDA in 1956

WHAT DOES THE FOOD PYRAMID CONSIST OF? Combines Dietary Guidelines + old

Basic Four Food Guide Divides food into 6 groups Designed to help reduce intake of fat &

concentrated sugars Doesn’t address fluid intake or combo foods Doesn’t guarantee consumption of necessary

levels of all essential nutrients

WHAT FACTORS AFFECT CHOICE OF FOOD? 1. Ethnicity & culture 2. Age 3. Religion 4. Economic status 5. Peer Groups 6. Personal Preference & uniqueness 7. Life-Style

(Con’t)

8. Beliefs About Health 9. ETOH Abuse 10. Advertising 11. Psychologic Factors 12. Health Status 13. Therapy 14. Medications

MEETING NUTRITIONAL NEEDS

HOW IS A NUTRITIONAL ASSESS. DONE? A. Anthropometric measurements B. Biochemical data C. Examine Pt. for clinical signs of

nutritional status D. Obtain Diet History

WHAT ARE ANTHROPOMETRIC MEASUREMENTS? 1. Direct Measurements=Height,

Weight, Skin fold measurements, Mid-upper arm circumference

2. Calculated measures= mid-upper arm muscle circumference, body mass index

WHAT BIOCHEMICAL DATA (6) CAN BE USED? 1. H & H 2. Serum Albumin 3. Transferrin 4. Total Lymphocyte count 5. Nitrogen Balance 6. Creatinine Excretion

WHAT ARE CLINICAL S/S OF NUTRITIONAL STATUS? 1. Hair 2. Skin 3. Eyes 4. Tongue 5. Mucous membranes 6. CV 7. GI 8. Nervous 9. Vitality 10. Weight

HOW IS A DIET HX DONE?

1. Includes Hx. About Pt.s usual eating patterns & habits, food preferences & restrictions, daily fluid intake, use of vitamin or mineral supplements, dietary problems, physical activity, Health Hx., concerns re. buying & preparing food

2. Do a 24-hr diet Hx 3. Ask re. Pt.s meds (especially pc or ac)

WHAT ARE SPECIAL OR THERAPEUTIC DIETS? A diet in which the amount of food or

the frequency of eating is prescribed Can be used to Tx. a disease process

or to prepare for special exam or surgery

Can be used to promote health Can be temporary or lifetime

WHAT ARE THE TYPES OF SPECIAL HOSPITAL DIETS? 1. Regular diet= no special needs 2. Light diet= postop Pt.; foods plainly

cooked; lge amts of bran & fat omitted 3. Soft diet= easily chewed & digested;

low-residue 4. Pureed diet= liquid is added to food

for semi solid consistency

(Con’t)

5. Full liquid diet= foods + liquids that turn to liquid at body temp.; is only short term; it is for Pt.s with GI disturbances; is monotonous

6. Clear Liquid = H2O = tea, coffee, clear broths, ginger ale or carbonated beverages, strained & clear fruit juices, plain jello, sugar & hard candy; relieves thirst

(Con’t)

7. Restricted Diets in Calories or Minerals e.g. =

a. 1800 Calorie ADA diet b. 2000 mg Na Diet

WHAT FACTORS DEPRESS APPETITE OF HOSPITALIZED PATIENTS?

1. Physical illness 2. Unfamiliar or unpalatable food 3. Environmental factors 4. Psychologic factors 5. Physical discomfort or pain

What principles Improve the appetite? 1. Relieve illness s/s= < pain,fever 2. Provide familiar food Pt. likes 3. Select small portions 4. Avoid unpleasant or uncomfortable Tx

around meal time 5. Provide tidy, clean environment 6. Encourage oral hygiene 7. Reduce psychological stress

WHAT ARE NSG. RESPONSIBILITIES WHEN PROVIDING MEALS? 1. Check Pt.s kardex or chart for

appropriate diet 2. Notify dietary staff of chgs in diet 3. Offer Pt. bathroom facility & hygiene 4. Assist with sitting if permitted 5. Clear overbed table or arrange table

close to bedside

(CON’t)

6. Assist Pt. prn with food preparation 7. For blind Pt. Identify placement of

food using clock image 8. Replace food covers & do I & O &

record % food taken after meal 9. If Pt. not eating notify nurse in

charge or dietician

WHAT ARE 2 GROUPS OF PTS. WITH SPECIAL NEEDS? 1. Elderly= weakened and quickly

fatigued when ill 2. Handicapped= blind Pts and those

who cannot use their hands or those who must remain in a back lying position

WHAT CAN BE DONE FOR THESE SPECIAL POPULATIONS? 1. Be sensitive to Pt.’s feelings of

embarrassment, resentment & loss of autonomy= Help Pt. feed himself; Try to appear unhurried ; Ask what order Pt. would like to eat food; use adaptive devices, allow ample time for chewing & swallowing; offer fluids, make pleasant conversation

WHAT PTS. ARE AT RISK FOR NUTRITIONAL PROBLEMS? 1. Any Pt. with a condition that

interferes with the ability to ingest, digest, absorb & metabolize nutrients

2. Pt.s with ^ demand for nutrients= pregnant women, hyperthyroidism, cancer

WHAT NSG. MEASURES ARE USED FOR FEEDING INFANTS? 1. Do not prop the bottle of formula 2. Start feeding solids at 6 months or as

per Pediatricians orders 3. Encourage breast feeding when

possible 4. Be cognizant of lactose insensitivity 5. Fluid needs of infants are

proportionately greater than adults

WHAT ARE INFANT VARIATIONS IN NUTRITION? Demand feeding Regurgitation Iron Deficiency anemia Bottle mouth Syndrome

WHAT NSG. MEASURES APPLY TO FEEDING TODDLERS? 1. Use finger foods 2. Be aware of food “Jags” 3. Offer fluids often 4. Allow parents to bring in food from

home when possible

WHAT ARE SPECIAL COMMUNITY NUTRITIONAL SVS? 1. Commodity Supplemental Food

Program 2. Emergency Food Assistance program 3. Food Stamp Program 4. Supplemental Food Program for

Women, Infants & Children (WIC)= provides food stamps & vouchers for pregnant &lactating women & children

WHAT ARE ALTERNATIVE FEEDING METHODS? (2) 1. Parenteral methods of nutrition=

Intravenous= TPN 2. Enteral= Gastrointestinal other than

Oral; Using : Nasogastric, Gastrostomy, Jejunostomy tubes; chg. Tube prn or per agency protocol

WHAT ARE THE PURPOSES OF A NASOGASTRIC TUBE? 1. Prevent nausea, vomiting & gastric

surgery post-op ( connected to suction) 2. To remove stomach contents for lab

analysis 3. To lavage (wash) stomach in cases of

poisoning or overdose of meds. 4. For feeding clients who are unable or

unwilling to take nutrients orally

HOW IS NG FEEDING DONE?

1. Specially prepared nutrients are instilled into the GI tract through a tube inserted through one of nostrils, down nasopharynx & into alimentary tract

2. Large-bore tubes are placed into stomach

3. Small-bore tubes are placed either into stomach or upper small intestine: duodenum or jejunum

HOW IS PLACEMENT VERIFIED WITH LARGE BORE TUBES? 1. Aspirate GI secretions 2. Measure the pH of aspirated fluid 3. Inject 5 to 20 ml of air through feeding

tube while auscultating epigastrum or Lft upper abd. Quad & listening for whooshing sound

4. Ask pt to hum or speak 5. Obs. Pt. for coughing & choking

WHAT IS THE TUBE FED PT. ASSESSED FOR? 1. Allergies to any food in the feeding 2. Bowel sounds prior to each feeding

or q 4-8 hrs with continuous feedings 3. Abdominal distention q day 4. Correct placement of tube before

feedings 5. Dumping symdrome

(Con’t)

6. Diarrhea, constipation or flatulence 7. Urine for sugar & acetone 8. Hematocrit & urine specific gravity 9. Serum BUN & Na levels 10. Presence of regurgitation & feelings

of fullness after feedings

WHAT IS A GASTROSTOMY FEEDING? Instillation of liquid nourishment through

a tube that enters a surgical opening through the abd. wall into the stomach; usually a temporary measure

Percutaneous endoscopic gastrostomy (PEG) is long-term

WHAT ARE THE TYPES OF ENTERAL FEEDINGS? 1. Bolus or intermittent 2. Continuous; use enteral feeding

pump ALWAYS PREVENT ASPIRATION

WHAT ARE PEDI CONSIDERATIONS FOR ENTERAL FEEDING? 1. Use pacifier while feeding to

maintain suck reflex 2. Prevent aspiration 3. Prevent tube dislodgment through

secure anchoring & frequent oral care

INTESTINAL ELIMINATION

WHAT ARE THE CHARACTERISTICS OF FECES? 1. Color 2. Consistency 3. Shape 4. Amount 5. Odor 6. Constituents

WHAT ARE COMMON FECAL ELIMINATION PROBLEMS? 1. Constipation 2. Fecal impaction 3. Diarrhea 4. Fecal incontinence 5. Flatulence

CAUSES & FACTORS= CONSTIPATION 1. Irregular defecation habits 2. Overuse of laxatives 3. Increased psychologic stress 4. Inappropriate diet 5. Insufficient fluid 6. Medications 7. Insufficient exercise

(con’t)

8. Age 9. Disease Process

DEFINING CHARACTERISTICS OF CONSTIPATION 1. Decreased frequency of defecation 2. Hard, dry, formed stools 3. Straining at stool; painful defecation 4. Palpable mass 5. Reports of fullness or pressure 6. Abd. Cramping or pain or distention 7. Use of laxatives, decreased appetite

NSG. INTERVEN. & RATIONALE FOR CONSTIPATION MGMT

WHAT IS FECAL IMPACTION? Mass or collection of hardened, puttylike

feces in folds of rectum Results from prolonged retention &

accumulation of fecal material Passage of liquid fecal seepage (diarrhea) &

no normal stool are defining characteristics Digital removal of impaction/ or enemas are

sometimes needed

WHAT ARE THE MAJOR CAUSES OF DIARRHEA?

BOWEL INCONTINENCE

FLATULENCE

Presence of excessive flatus in intestines Primary Causes: 1. Action of bacteria on chyme in large

intestine 2. Swallowed air 3. Gas diffusing into intestine from

bloodstream

COMMON CAUSES OF FLATULENCE 1. Constipation 2. Codeine, barbituates (anesthetics) 3. States of anxiety during which large

amts. of air are swallowed 4. Dietary changes 5. Decreased activity

DECREASING FLATULENCE

1. Decrease gas-producing foods 2. Encourage exercise 3. Reposition clients 4. Insert rectal tube & leave in rectum

for no longer than 30 mins 5. Admin. Return flow enema

DIAGNOSTIC STUDIES OF GI

1. Direct visualization techniques=endoscopic studies

2. Indirect visualization=roentgenography through use of barium

3. Lab tests for abnormal consituents=stool samples for lab; bedside testing for occult blood= Guiac

WHAT ARE THE TYPES OF LAXATIVES? Laxative= mild drug that induces

defecationwith frequent, soft or liquid BM + abd cramps

Cathartic=strong drug that induces defecation with purgative effect

Contraindicated in Pt. with n/v, cramps, colic, undiagnosed abd. Pain

WHAT ARE ANTIDIARRHEAL MEDS? Decrease defecation frequency “Guideines for Using Antidiarrheal

Medications”

WHAT ARE ENEMAS?

A sln. Introduced into the rectum & sigmoid colon

4 groups= cleansing, carminative, retention, return flow

Cleansing Enema Types of Solutions (4)= hypertonic, hypotonic, isotonic, soap, oil

WHAT ARE COMMONLY USED ENEMA SLN. ACTIONS & ADVERSE EFFECTS?

WHAT IS A BOWEL DIVERSION OSTOMY? Opening into the abdominal wall for

elimination of feces or urine 1. Ileostomy 2. Colostomy 3. Gastrostomy 4. Jejunostomy 5. Ileal conduit

HOW ARE BOWEL DIVERSION OSTOMIES CLASSIFIED?

1. Permanence 2. Anatomic location 3. Construction of stoma

HOW ARE STOMAS ASSESSED?

1. Color 2. Size and shape 3. Bleeding 4. Status of peristomal skin 5. Amt & type of feces from stoma=

effluence 6. complaints

NSG. INTERVENTIONS FOR APPLIANCE CHANGE

TOILET TRAINING OF CHILDREN Daytime control is normally attained by

age 2 1/2 yrs. 1. Provide clothing child can remove

independently 2. Give child personal, comfortable seat 3. Allow sufficient time 4. Offer positive reinforcement

(Con’t)

5. Avoid punishment or disapproval 6. Initiate toilet training during

nonstressful periods of child’s life

WHAT FACTORS AFFECT DEFECATION? 1. Age & development 2. Diet 3. Fluid 4. Activity 5. Psychologic factors 6. Life-style 7. Medications

(Con’t)

8. Diagnostic Procedures 9. Anesthesia & Surgery 10. Pathologic Conditions 11. Irritants 12. Pain