Module 5 - Gastrointestinal System Flashcards
(139 cards)
1
Q
GI Conditions
A
Nutrition constipation Diarrhea Nausea and vomiting Gastroesophagea, Reflux Disease (GERD) Peptic Ulcer Disease (PUD) Inflammatory Bowel Disease (IBD) Irritable Bowel Syndrome (IBS) Pancreatitis Hemorroids
2
Q
What is the function of the digestive system?
A
To extract nutrients from food to fuel metabolic processes in the body.
3
Q
Name the major parts of the Digestive system and their function.
A
Upper GI: Mechanical and chemical digestion Lower GI (sm intestine): primary organ for absorption of nutrients Lower GI (leg intestine): Major site of Water reabsorption Liver: most important accessory organ - first pass effect; enterohepatic recirculation.
4
Q
what two factors regulate digestion?
A
Hormonal and nervous factors
5
Q
Def: vitamins
A
Substances that are required in small amounts for normal growth and nutrition
6
Q
Water-soluble vitamins
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Stored briefly in the body and then excreted in urine.
7
Q
Lipid-coluble Vitamins
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Stored in liver and fatty tissue. *possibility of toxicity (Vitamins A, D, E, and K)
8
Q
Def: minerals
A
Essential substances that serve many diverse functions - act as ions and electrolytes, important component of hemoglobin and enzymes
* possibility of toxicity
9
Q
Conditions requiring nutrition intervention
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Severe infections (HIV, AIDS) States of malnutrition bowel rest for inflammatory bowel disease coma eating disorders Post-surgeical complications major burns and trauma neuromuscular and CNA disorders advanced age prematurity chemotherapy
10
Q
Indications for Enteral Nutrition
A
for patients with functioning GI tract but are unable to orally ingest adequate amounts of nutrients to meet their metabolic needs (includes PO and feeding tubes
11
Q
Def: parenteral nutrition
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Administration of high-caloric nutrients via a central or peripheral vein AKA Total Parental Nutrition (TPN)
12
Q
Routes of administration: Enteral Nutrition
A
Bolus, intermittent drip or infusion, continuous infusion, or cyclic intermittent infusion
13
Q
Polymetric Enteral nutrition formula
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pictures of protein, lipids, carbs
14
Q
Elemental Enteral nutrition formula
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amino acids and small amount of fats
15
Q
Semi-elemental Enteral nutrition formula
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slightly larger molecules than elemental
16
Q
modular Enteral nutrition formula
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disease-specific
17
Q
What are the main four classes of nutrients that can be found in most enteral neutron formulas?
A
- Carbohydrates
- proteins
- lipids
- vitamins and minerals
18
Q
complications of enteral nutrition
A
Aspiration nausea and vomiting diarrhea referring syndrome clogged feeding tube interrupted infusions
19
Q
can drugs that are to be administered orally be given via an enteral feeding tube?
A
yes.
20
Q
can enteric coated drugs, time release, sub-lingual medications, or bulk-forming laxatives be given via the enteral route?
A
NO. best bet is to double check with pharmacy - but they meds should not be given via enteral tube
21
Q
Indications for Parenteral Nutrition
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When a patient can no longer receive enteral feedings
22
Q
Components of Total Parenteral Nutrition
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Carbohydrates lipids amino acids electrolytes minerals vitamins
23
Q
complications of parenteral nutrition
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mechanical - improper positioning of catheter can have severe consequences (fluid or air into cavities, clotting)
Metabolic - electrolyte and mineral imbalances, bone and mineral deficiencies, gallstones, fatty liver, blood sugars.
infection - an easy site for infection, be sure to use aseptic techniques and monitor for infection
24
Q
Def: Constipation
A
Infrequent and/or unsatisfactory defecation fewer than 3x per week. may also include passing hard stools, straining, incomplete or painful defecation.
- subjective experience
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Life style changes that help manage constipation
- increase water intake
- increase soluble fibre intake
- increase physical activity
- weight loss
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Classes of medication for Constipation
1. Bulk-forming agents
2. Osmotic agents
3. Stimulants
4. Stoll softeners
5. Lubricants
6. Suppositories and Enemas
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MOA: Bulk-forming Agents
Ferment in the colon causing gas formation, increased osmotic load, water retention and wall stress which stimulates motility.
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Considerations: Bulk-forming Agents
Usually takes a few days for relief
need adequate fluid intake (more than 250mL)
not easy to swallow
may alter absorption of Fe 3+, Ca 2+, vitamins, and other medications
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Adverse effects: Bulk-forming Agents
Flatulence
| bloating
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MOA: Osmotic Agents
Contain poorly absorbed ions or molecules that create an osmotic gradient to retain water within the intestinal lumen. the increased pressure on the intestinal wall induces gastric motility
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Indications: Osmotic Agents
Used for bowel evacuations before procedures (high frequent dosing) OR for daily maintenance/prevention (Low, daily dosing)
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Some examples of Osmotic agents
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Glycerin (suppository)
Lactulose
Polyethylene glycol (PEG) 3350
Magnesium citrate
sodium phosphate
magnesium hydroxide (milk of magnesia)
```
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Adverse Effects: Osmotic Agents
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Nausea
abdominal bloating
cramping
diarrhea
flatulence
skin rashes/ hives
*all are rare and more prevalent with higher doses
```
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MOA: stimulants
Stimulate smooth muscle to produce rhythmic contractions. dosing is very variable between patients.
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Indications: Stimulants
Typically if Osmotic laxatives have failed or were not well tolerated
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Examples: Stimulants
Senna/sennosides (Senokot,)
Bisacodyl (Dulcolax)
Sodium picosulfate(pico-salex)
Castor Oil
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Expected outcomes: Stimulants
BM within 6-12 hours (often overnight use)
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Expected outcomes: Osmotic Agents
BM within 30 mins (high frequent doses) within 3 days (low daily doses)
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Adverse effects: Stimulants
```
Bloating,
abdominal discomfort
flatulence
diarrhea
*highest incidence of cramping and pain
```
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MOA: Stool softeners
Act as a surfactant which results in better mixing of aqueous and fatty substances to soften the fecal mass.
* more of a preventative measure.
* may not be any better than a placebo and many hospitals and facilities are moving to more effective treatments.
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Expected outcomes: Stool softeners
BM in 1-5 days
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Adverse effects: Stool softeners
Bloating,
abdominal discomfort
flatulence
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MOA: Lubricants
Lubricates contents of GI tract and keeps water in GI tract. (mineral Oils)
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Contraindications: Lubricants
limited use after MI or Rectal surgery
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Contraindications: stimulants
avoid in pregnancy
| avoid if sensitive to electrolyte or fluid abnormalities
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Expected outcome: Lubricants
Allergic reactions
anal seepage
alteration of vitamins/minerals/ and of the medication
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MOA: Suppositories and Enemas
Precence of object in rectum stimulates defecation reflex - in addition to any benefits provided by specific ingredients (osmotic agents, lubricants)
For acute relief or bowel for procedure
*not for management of chronic constipation
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Expected outcomes: Suppositories and Enemas
Cleansing of bowel within 1 hour. if no BM *Call physician
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Adverse Effects: Suppositories and Enemas
Discomfort
bloating
cramping
allergic reactions
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Nurse's role: Constipation
Assessing bowel sounds and patterns
assess previous therapy, comfort level, and pt expectations
adequate fluid intake
Lifestyle recommendations/teaching for measures of prevention for chronic constipation
educate on "normal" (3x/day - every 3 days)
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monitoring: Constipation therapy
Fluid and electrolyte balance, obstruction, abdominal cramping, time and appearance of BM (and documenting), bleeding, severe pain
* Do not give Magnesium or aluminum products for patients with kidney impairment.
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Consideration for laxative containing magnesium
magnesium containing laxatives (like milk of Magnesia) may have interactions with other drugs due to Drug-binding, which inhibits absorption, If possible separate by 2hrs
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Def: Diarrhea
Unusually frequent excretion of watery stools. associated with loss of electrolytes and fluid leading to dehydration.
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Symptoms of Dehydration in Children
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Dry mouth, tongue and skin
Few or no tears when crying
Decreased urination (<4 wet diapers in 24hrs)
sunken eyes, cheeks, abdomen
greyish skin
Sunken fontanelle (soft spot) in infants
Decreased skin turgor
Irritability or listlessness
```
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Symptoms of dehydration in Adults
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Increased thirst
decreased urination
feeling weak or lightheaded
Dry mouth
decreased skin turgor
```
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Ways to achieve Rehydration
Increase water intake
Balanced electrolyte oral rehydration solutions
Home made solution (1 teaspoon salt and 6 teaspoons sugar in 1 litre of water)
Half strength apples juice (for children)
IV rehydration if severe
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Classes of Antidiarrheals
1. Absorbing agents
2. anti motility agents
3. Antisecretory agents
4. bulk-forming agents
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Adverse Effects: Lubricants
Allergic reactions
anal seepage
alteration of Vitamins/ minerals/ drugs
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MOA: absorbant agents
Absorbs fluid in intestine, reducing stool liquidity. May give some relief very safe (can be used in children)
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MOA: anti motility agents
Opiod agonists that do not cross Blood-Brain barrier. No dependent or tolerance with long term use
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MOA: Antisecretory agents
Pepto-bismol! \Stimulates absorption of fluid and electrolytes across intestinal wall, also bactericidal and anti-inflammatory - NOT for children.
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MOA: Bulk-forming agents
Identical mechanism as with constipation, create gel - using excess fluid in GI tract
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MOA: Loperamide (Imodium)
Slows intestinal motility by stimulating opiod receptor, which reduces fecal volume and increases viscosity
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Adverse effects: Loperamide (Imodium)
```
Cramping
discomfort
skin rash
dry mouth
possible CNS - usually only if blood brain barrier is compromised results in drowsiness, dizziness, confusion (rare)
```
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Monitoring: Diarrhea therapies
Frequency and consistency of BM
Continue assessment of signs of infection
hydration level - rehydrate all patients with diarrhea often to prevent dehydration
all products have potential to cause constipation
monitor for CNS effects in children and elderly using loperamide
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Nurse's role: Diarrhea
Assess for causes of diarrhea - infection, medication, IBD, assess hydration level and electrolyte replacement needs.
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Def: nausea and Vomiting
Nauseas: unpleasant sensation of the imminent need to vomit
vomiting: the forceful expulsion of gastric contents with contraction of the abdominal chest wall musculature
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Most common causes of nausea and vomiting
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Migraine
gastroenteritis
non-ulcer dyspepsia
noxious odours
pregnancy
motion sickness
postoperative
medication
```
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Other (less common) causes for Nausea and vomiting
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Head trauma
ketoacidosis
otitis media
cholecystitis
gastroparesis
pancreatitis
increased intracranial pressure
kidney disease
appendicitis
gastric/intestinal obstruction
hepatitis
peptic ulcer disease
```
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Medications that are used as Antiemetics
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Antacids
Anticholinergics
Antihistamines
Dopamine antagonists
Benzodiazepines
Butyrophenones
Corticosteroids
Phenothiazines
Serotonin Antagonists
Neurokinin-1 Antagonists
```
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Antiemetics used for Nausea and vomiting r/t Higher Brain centre triggering the vomiting centre
Cannabinoids
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antiemetics used for Nausea and Vomiting r/t to stimulation of the vomiting centre by the Vestibular Apparatus
Anticholinergics
| Antihistamines
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Antiemetics used for Nausea and Vomiting r/t stimulation of the vomiting centre by the GI tract
Serotonin Recepto Antagonists
| Dopamine Antagonists
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Antiemetics used for nausea and vomiting r/t stimulation of the vomiting centre by the chemo0receptor trigger zone
Serotonin receptor antagonists
Dopamine Antagonists
NK1 Antagonists
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MOA: Dimenhydrinate
(Gravol)
An antihistamine (with anticholinergic activity
** only effective for nausea and vomiting r/t motion sickness (vestibular apparatus)
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Adverse effects: Dimenhydrinate
Drowsiness and Anticholinergic effects -dry mouth, constipation, urinary retention, confusion, tachycardia.
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MOA: Doxylamine and Pyridoxine
Specifically for Nausea and vomiting during pregnancy
MOA largely unknown
Doxylamine = Antihistamine
Pyridoxine = Vitamine B6
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Adverse effects: Doxylamine and Pyridoxine
Drowsiness, fatigue.
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MOA: Domperidone
A peripheral dopamine antagonist, that blocks dopamine receptors in the GI tract; also has pro-kinetic properties, which increases peristalsis to improve gastric emptying rates.
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Primary Use: Domperidone
Antiemetic for multiple GI conditions, prevention of nausea and vomiting with concurrent medications (chemo), enhances milk production, GERD
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Adverse Effects: Domperidone
Headache, menstrual irregularities, dry mouth, diarrhea, abdominal discomfort
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MOA: Ondasetron
Serotonin receptor antagonist in chemoreceptor trigger zone and along GI tract (CTZ)
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Primary use: Ondasetron
Chemotherapy induced nausea and vomiting
| occasionally used in severe nausea and vomiting in pregnancy
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Adverse effects: Ondasetron
```
Head ache
dissiness
drowsiness
constipation
diarrhea
(all rare)
```
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Nurse's role: Nausea and vomiting
Assess for causes of nausea and vomiting
assess hydration level and rehydrate as necessary
recognize that dimenhydrinate had only shown effectiveness for motion sickness, in spit of its prevalence of use for viral gastroenteritis
Patient teaching
encourage adherence to post-chemo meds
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Def: Dyspepsia
Ingestion, abdominal fullness, heartburn, nausea, belching or upper abdominal pain
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Def: Gastroesophageal Reflux Disease (GERD)
Mucosal Damage caused by stomach acid rising up from the stomach into the esophagus (chronic heart burn) can lead to an ulcer in the esophagus
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Def: Esophagitis
Inflammation of the tissues of the esophagus
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Def: peptic Ulcer Disease (PUD)
A lesion in the mucosal lining of the stomach or small intestine (commonly caused by H. Pylori)
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Pharmacotherapy goals for PUD and GERD
1. Reducing the acidity of gastrointestinal secretions to allow surrounding tissue to heal
2. Destroying Bacteria (if present)
ALSO remove causative agent (if possible)
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Classes of medication for PUD and GERD
1. H2-antagonists
2. Proton Pump Inhibitors (PPIs)
3. Sucralfate
4. Antibiotics
5. Antacids
6. Misoprostol
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H1 vs H2 receptors
H1 - sm muscle of vascular system, bronchial tree, digestive tract - inflammation, allergies, anaphylaxis
H2 - lining of stomach - produce acid in stomach
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MOA: H2-Antagonists
- TIDINE
Blocks H2 receptors which prevents acid secretion, reduces volume and acidity of secretions, allowing a lesion to heal.
*lost of drug interactions
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considerations: H2-Antagonists
Most effective if taken regularly (daily)
CAN be used PRN for Heart Burn - by anyone
very safe
smoking decreases effectiveness
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Adverse Effects: H2-anatagonists
Headaceh
dizziness
drowsiness
less common: nausea, vomiting, constipation, diarrhea.
Very rare: reduction of RBC, WBC and platelets, bradycardia, allergic reactions
* can potential interact with absorption of other drugs or vitamins. (anything that need acid for absorption)
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MOA: Proton Pump Inhibitors (PPIs)
-PRAZOLE
Proton pump = cells that are present in the lining of the stomach, their job is to 'pump' protons (H+) into the stomach for acid secretion. PPIs inhibit this, preventing acid secretion, creating less acidic environment for lesion to heal.
Decrease acidity more than H2-antagonists.
*not effective to use PRN for heart burn
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Adverse effects: Proton Pump Inhibitors
Very well tolerated
may experience: headache, diarrhea, flatulence, nausea, abdominal pain
long-term use: decrease in bone mineral density and others.
* Rebound acid hyper-secretion when therapy is discontinued - only last short period, treated with H2-anatagonist and/or antacid PRN.
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MOA: Sucralfate
A cytoprotective agent that adheres to and then protects ulcerated gastric or duodenal mucosa. contains aluminum, which lowers acidity of gastric contents.
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Adverse effects: Sucralfate
```
Constipation or diarrhea
nausea
headache
indigestion
dry mouth
may increase Blood Glucose
very rarely: bezoars (solid build up of indigestible material in GI) have been reported in some patients. usually only in those with comorbibities.
```
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MOA: antibiotics (GERD and PUD)
Must be specific for h. Pylori -blood test to confirm presence.
Eradication of h. pylori allows ulcers to heal more rapidly and remain in remission longer, often permanently.
*two antibiotics are always given concurrently to in crease effectiveness and reduce chance of resistance.
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MOA: antacids
Neutralize acid that is already present - do NOT have an effect on future acid secretion - supportive role only
used PRN
- can interact with many medications and should be separated by 2hrs
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Cautions: antacids
Patients with kidney disease or poor renal function - magnesium and aluminum can be toxic due to accumulation (calcium too)
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Adverse effects: Antacids
Calcium - constipating
| Magnesium and Aluminum - Diarrhea and can make stool a whiter colour
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MOA: Misoprostol
A mucosal protective agent occasionally used to prevent GI adverse effects of long-term NSAID use - also used for medically-induced abortions and to evacuate uterus after miscarriage
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Adverse Effects: Misoprostol
```
Headache
abdominal cramps
diarrhea
vaginal bleeding
uterine cramping
*DO NOT USE IN PREGNANCY*
```
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Monitoring PUD and GERD
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Assess initial symptoms (include signs of GI bleed) and current medications
assess need for PRN medications
signs of bowel obstruction
Monitoring associated with antibiotics
monitor for prolonged use of PPIs
```
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Nurse's role: PUD and GERD
Lifestyle modification teaching
Ensure Compliance
avoid giving acid reducing drug along with other meds
avoid magnesium and aluminum antacids in its with kidney problems
encourage smoking cessation
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Def: Inflammatory Bowel Disease (IBD)
self explanatory. alternating periods of exacerbation and remission. auto immune condition that cause inflammation in bowel and GI tract.
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Classes of medications for IBD
1. Aminosalucylates
2. corticosteroids
3. immune-auppressants
4. biologics
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MOA: amino salicylates
Anti-inflammatories (a GI topical effect) - inhibit production of inflammatory mediators, prostaglandins and leukotrienes
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indications: Aminosalicylates
For mild symptoms. would not treat an exacerbation. used to lengthen times between exacerbations
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Adverse effects:Aminosalicylates
```
Nausea
diarrhea
abdominal pain
headache
rash
rhinitis
photosensitivity
```
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MOA: corticosteroids (IBD)
useful because of both anti-inflammatory and immunosuppressant activity
used to treat exacerbations to send disease into remission
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MOA: Immune-Suppressants (IBD)
Suppresses auto-immune component of disease only.
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Indications: Immune-suppressants (IBD)
For more severe disease, when aminosalicylates are not enough to prevent exacerbations.
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Adverse effects: Immune suppressants (Methotrexate for IBD)
Ulcerative stomatitis, leukopenia, nausea, abdominal distress, malaise, fatigue, chills and fever, dizziness, decreased resistance to infection
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MOA: Methotrexate (immune-suppressant)
Folate antagonist, interfering with DNA synthesis, repair, and cellular replication.
*requires folic acid to be replaced
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MOA: Biologics (IBD)
some have anti inflammatory properties and some have immune-suppressive property, some have both. most work as immunosuppressant-suppressants
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Def: Irritable Bowel Syndrome
Abdominal pain or discomfort with altered bowel habits which occur over a period of at least 3 months. large association with mental health - symptoms are REAL but no physical cause can be found.
120
Treatment of IBS
Treatment is till and error, based on predominant chronic symptom (constipation or diarrhea)
treatment with antidepressants and anti-anxiety meds also viable and common options
50% placebo effect
Non-pharmacological options (such as social support) is more import and more effective than drugs
121
Pharmacotherapy in IBS
1. Antispasmodics
2. calcium channel
3. blockers
4. opioid agonists
5. antidepressants
6. osmotic and stool softeners
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MOA: antispasmodics (IBS)
reduce muscle spasms of GI tract by blocking muscarinic receptors (anticholinergic effects)
123
MOA: Calcium Channel blockers (IBS)
Very specific for GI smooth muscle, reduces muscle contractions by inhibiting calcium reflux (hypotension)
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MOA: opioid agonists (IBS)
Doesn't cross Blood-brain barrier - anti serotonin activity
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MOA: antidepressants (IBS)
adress neurological connection and overlap of neurological conditions with IBS
126
MOA: osmotic and stool softeners (IBS)
Used for prevention or as needed
127
Def: pancreatitis
acute or chronic inflammation of the pancreas (very painful)
usually caused by gallstones, heavy alcohol use, or cystic fibrosis
128
MOA: Pancreatic enzymes
administered as therapy for patients with chronic pancreatitis. supplementation send negative feedback message to stop secreting endogenous pancreatic enzymes, which can reduce pain.
129
Treatment for pancreatitis
Pain management
bed rest
fasting
adequate electrolyte and fluid therapy
H2-antagonists and PPis to reduce gastric secretions.
TPN (total parenteral nutrition) may be necessary during recovery to avoid pancreatic stimulation
130
Nurse's role: IBD, IBS, Pancreatitis
Monitoring of pain symptoms, response to treatment, bowel, movements, urine output, liver and kidney function, and red flags
awareness of importance of emotional impact and support
recommend support groups that are available
be a supportive resource
teaching for immune-suppressants and biologics
131
def: diseased hemorrhoids
The existence of hemorroidal cushions alone does not constitute disease - once symptoms appear (typically bleeding, itching, protrusion or pain) due to swelling and/or prolapse, then hemorrhoids are diseased.
132
causes of Hemorrhoids
commonly seen with: Constipation, diarrhea, pregnancy, advancing age and possible exertion.
133
med classes: hemorrhoids
symptom relief only - no cure
1. local Anaesthetics
2. corticosteroids
3. Astringents
4. anti-infectives
5. protectants
134
MOA: Local anesthetics (hemorrhoids)
to relieve pain
| *safe for <7days of continued use
135
adverse effects: Local anesthetics
With longer use: possible CNS effects and cardiovascular effects
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MOA: corticosteroids (hemorrhoids) and Adverse effects
to reduce inflammation.
*safe for <14 days of continued use
longer use results in Mucosal atrophy
137
MOA: Astringents (hemorrhoids)
dries out skin to relieve burning, itching, and pain.
| no adverse effects
138
are opioids appropriate to use for pain r/t hemorrhoids?
NO. opioids cause constipation which will make hemorrhoids worse.
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monitoring: hemorrhoids
Assess relief of symptoms
symptoms worsen, significant bleeding or seepage, prolonged use of products, CNS or Cardiovascular effects --> refer to physician
assess diet
monitor constipation
