INTERFERENCES WITH NUTRITION: UPPER GI
Normal GI Tract
Organs of Digestion
Mouth: salivary glands; CHO (starch) digestion
Esophagus: hollow tube from pharynx to
stomach
Stomach: stores and mixes food with gastric
juices and mucus forming chyme
-pepsin: protein digestion
-intrinsic factor: helps with vitamin B12
absorption
GI SYSTEM
• Small Intestine
– Duodenum: first part of intestine connecting
to stomach with intestinal juices
that are alkaline
– Jejunum: middle portion
– Ileum: lower portion
Large Intestine
–
–
–
–
Cecum ( with appendix)
Colon
Rectum
Anus
• Accessory Digestive Organs
– Liver: largest internal organ which
metabolizes fat, glucose, protein
- produces bile
- stores vitamins A,B,D and some B
complex
- coagulation factors
– Gall Bladder: under liver; concentrates and stores bile
(emulsifies ingested fats)
• Pancreas
Exocrine: trypsin and chymotrypsin for
protein
- amylase for starch
- lipase for fat
Endocrine: insulin
• GENERAL GI FUNCTION: Digestion
Absorption
Elimination
• DIAGNOSTIC TESTS
Lab tests (blood)
- amylase & lipase: increase with
pancreatic problems
- albumin: produced by liver cells
(decreased in cirrhosis)
- LDH: shows liver damage
• Stool Examination
-check for presence of:
blood
bacteria
parasites
• Gastric Analysis
- shows presence/absence of acid
- check for carcinoma cells
• PROCEDURES
Abdominal Ultrasonography: non-invasive using high
frequency sound waves
Upper/Lower GI series: visualizes structures and
motility of the stomach
Barium Swallow: shows esophageal lesions,
hernia
• Upper/Lower Endoscopy: direct visualization of the
GI tract
- Colonoscopy
- Sigmoidoscopy
• CAT Scan: (non-invasive) checks for structures,
tumors
• MRI: checks for structures, abnormalities
(pt. cannot have any metal implants)
THINK - PAIR - SHARE
• Discuss the follow-up care following
• The diagnostic studies of the GI tract
– -upper endoscopy
– -barium enema
– -colonoscopy
• General Nursing Interventions
Preparation
- informed consent
- pt. usually fasts 8 – 12 hours or more
- diet may be low fat, low residue, clear liquids
- check for allergies if contrast is being used
- enemas may be given for lower GI studies
Post Procedure
- monitor vital signs
- follow up care if barium used for study
• Impairments to Intake
Obesity: 2x the ideal body weight or 100 lbs.
or more over the ideal body weight
Etiology/Pathophysiology: physiological, social,
or psychological interrelationships
Other factors: possible genetic
CNS disturbance
hormonal (thyroid, BMR)
Body Mass Index= 703 x wt. in lbs.
(height in inches)2
• Nursing Interventions
Diet: most important method of weight reduction
with well planned meals ( 4 basic groups/ caloric
intake
Exercise: second part of weight reduction (burns
calories and affects plasma & lipid levels
- increases muscle tone
• Medication
Appetite suppressants
Sibutramine Hcl (Meridia): decreases appetite
by inhibiting reuptake of serotonin and
norepinephrine (SE: increases BP)
Alters Digestion
Orlistar (Xenical): decreases caloric intake by
preventing digestion of fats (SE: increased BM)
• Behavior Modification
Promote change in eating habits and lifestyle
• Bariatric Surgery
Jejunoileal bypass: pouch with a small capacity
created
Gastric bypass and vertical gastroplasty (most
frequently used): pouch with a smaller capacity
created
• Nursing Interventions (post op)
Help reduce anxiety
Pain control
Observe for potential complications
- peritonitis
- stomal problems
- respiratory problems (atelectasis/pneumonia)
- vomiting/ diarrhea ( metabolic imbalances)
- 6 small feedings; encourage po intake
Studies regarding p/o bariatric surgery
• Changes in metabolism
• Malnutrition
Etiology/ Pathophysiology
related to decrease in nutrient intake
increase in nutrient losses
increase in nutrient requirement
(body depends on proteins for 8 amino acids it can’t produce)
Negative Nitrogen Balance
Using more than taking in: decrease in albumin will decrease
osmotic pressure leading to interstitial fluid
• Malnutrition
interferes with wound healing
increases susceptibility to infections
increases incidence of complications ie. GI,
mechanical or metabolic
Assessment: Subjective- dietary likes/dislikes, ability
and desire to eat, financial
Objective- height, weight, lab data such as H&H
and albumin, S&S of infection or skin breakdown
• Nursing Interventions
Encourage po intake: fluids, supplements (ensure)
Tube Feedings (nasogastric)
Levin (single lumen): can be used for suctioning,
meds, feedings
Gastric sump (Salem): double lumen used to
decompress the stomach
Dobhoff: tungsten weighted that takes about
24 hrs to pass; pt. lies on right side to
facilitate passage
Gastrostomy: surgical procedure creating an
opening in the stomach to provide nutrition
-benefits are gastroesophageal sphincter remains
intact so less of a chance for regurgitation
Cantor tube: weighted tip with mercury, water, saline
used for decompression of the intestines
• Nursing Care
Instruct regarding insertion
Cetacaine to numb area
Instruct to swallow
Confirm placement/positioning by x-ray, NG
aspirate (gastric pH 3, intestine pH 6.5),
measurement of tube length
Comfort measures: HOB up 30 for 1-2hrs after feed
• Nursing Care (continued)
Check tube patency & residual ( no more than
10-20% >hourly rate)
Monitor for nausea & vomiting
Provide oral/nasal hygiene
Monitor electrolytes, I & O
Check for metabolic acidosis
Flush tube with water
Think- Pair- Share
• Compare and Contrast the advantages
• and disadvantages of the following tubes for
enteral nutrition:
– nasogastric (NG) tube
– Nasointestinal (NI) tube
– Gastrostomy tube
used to feed the child with a
gastrointestinal disorder such as
esophageal atresia.
• Tube Feeding Formulas
High molecular weight: protein, CHO, fats -2cal HN
Chemically defined formulas containing predigested
and easy to absorb nutrients-Osmolite HN
Modular products that contain 1 major nutrient
such as protein- Promote
Fiber added to try to decrease diarrhea- Jevity
• Dumping Syndrome
Increased concentration of tube feeding causes
water to move to stomach and intestines
thereby making the pt. feel full with nausea
diarrhea
Pt. develops dehydration, hypotension and
tachycardia
Total Parenteral Nutrition (TPN):
- hypertonic solution[10%/20%/50%]
providing calories and nutrition
- contains amino acids, lytes, vits, minerals, and
trace elements
- prepared aseptically
- keep refrigerated ( use with 24-36 hrs)
• Method of Administration
(Since it’s concentrated, give into larger vessel)
Nontunneled central catheters (subclavian)
Percutaneous Subclavian
PICC lines
Tunneled central caths Hickman
Implanted ports
Nursing Care
Check insertion site to prevent infection/sepsis
Prevent mechanical problems
Check I&O, daily wts., fluid & lyte balance
Monitor glucose
If new TPN not available, hang up high
concentration (D 10%)
D/C TPN gradually
•
Fluid and Electrolyte Balance/Problems
(GI tract has increased lyte content)
Etiology: loss of secretions from vomiting, diarrhea
and suctioning r/t intestinal parasites, virus
Assessment: N&V, wt. loss, bowel patterns, abdomen
bowel sounds and pain
Deficits:
Metabolic alkalosis- loss of gastric acid ( suctioning
or vomiting)
Metabolic acidosis-loss of bicarbonate secretion from
diarrhea or intestinal fistulas
• Problems
Nausea & vomiting (2 centers in medulla can
trigger vomiting leading to altered nutrition,
lyte imbalance, metabolic alkalosis, dehydration
Dehydration (poor intake)
assessment- poor skin turgor
sunken eyes
dry membranes
Nursing Interventions
-Treat nausea/vomiting with meds
- diet
-Treat dehydration
increase fluids
IV fluids
• Gastroesophageal Reflux Disease (GERD)
Lower esophageal sphincter (LES) allows reflux of the
stomach contents back into the esophagus
Assessment: heartburn & regurgitation occurs shortly after
eating when bending over or lying down;
dyspepsia; dysphagia; esophagitis (can mimic
heart attack symptoms)
• Nursing Interventions
Antacids: magnesium hydroxide/aluminum
hydroxide (MOM)
Histamine blockers: ranitidine (Zantac)
Proton Pump Inhibitors: lansoprazole (Prevacid)
Prokinetic agents: accelerate gastric emptying
metoclopramide (Reglan) S.E.= CNS problems
Drugs to promote gastric emptying; avoid spicy,
acidic, caffeinated & fatty foods
Remain sitting up after eating
• Structural Defects
Cleft Lip/ Cleft Palate
Cleft Lip
Cleft Palate
opening in upper
openings in hard and/or
lip or to nasal septum
soft palate
Assessment:
easily recognizable
seen on thorough exam of
mouth
Figure 24–3 (continued) A, Unilateral
cleft lip. B, Bilateral cleft lip. Courtesy
of Dr. Elizabeth Peterson, Spokane, WA.
B
Feeder (B) both have longer, softer
nipples and make it easier for the child
to feed from a bottle.
A, photo courtesy of Mead Johnson &
Company; B, courtesy of Medela AG,
Switzerland.
A
B
• Psychological Assessment of Parents
Nursing Responsibilities
Emphasize positive aspects of infant
Surgical intervention
Advise of long range problems (speech)
• Therapeutic Management (surgical repair)
Cleft Lip
Cleft Palate
by 2- 3 months
by 18 months
staggered suture line
wait for palatal changes
• Nursing Interventions
Cleft Lip
Cleft Palate
Monitor VS; I&O
Monitor VS; I&O
Protect surgical site
Position on abdomen
Keep suture line clean
Protect suture line
(NS/ sterile water)
Oral packing 2-3 days
Sedation/analgesia
Nutrition( blenderized from cup)
Lie on back/side
Cleanse after feeding
Gently aspirate if needed
Logan Bar: protect site
Developmental appropriate activites
• Feeding problems
- can’t make tight seal
- need special devices:
- Bulb
- asepto
- Brecht syringes
- positioning:
-upright position
- frequent burping
-nipple must make seal
• Esophageal Atresia (tracheolesophageal fistula) TEF
Pathophysiology: failure of esophagus to develop as
continuous passage in a variety of ways
Assessment
excessive salivation/drooling, sneezing
the 3 C’s: coughing, choking, cyanosis
Therapeutic Management
Prevent pneumonia by preventing aspiration of fluids
antibiotics if needed
Surgery: NPO, IV’s, positioning, ligation of fistula with
end to end anastomosis
• Nursing Interventions
Early identificaton
NPO & IV’s
Keep blind pouch empty ( suctioning)
HOB down
Infant in incubator with O2
Meet nutritional needs with gastrostomy tube
• Hernias
Pathophysiology (various types)
protrusion/ projection of an organ through the
muscle wall
Assessment
Diaphragmatic: abdominal contents protrude through
muscle into cavity
Respiratory distress with absent breath sounds
possibly hear bowel sounds
Davis, H. (Eds.). (2002). Atlas of
pediatric physical diagnosis (4th ed., p.
43). Philadelphia: Mosby. Note: From
Zitelli, B., & Davis, H. (Eds.). (2002).
Atlas of pediatric physical diagnosis
(4th ed., p. 43). Philadelphia: Mosby.
Management/ Nursing Care
Prep op
Post op
HOB elevated
Monitor VS; I&O
NGT
Check for S&S of infection
Respiratory support
Monitor fluid & lytes
IV’s
Position on affected side
• Umbilical Hernia
Weakness of umbilical ring & will protrude with
crying, coughing, straining
Most defects resolve spontaneously by 3-4 yrs
Surgery if other measures don’t work
• Pyloric Stenosis
Pathophysiology: narrowing of pyloric canal
between stomach and duodenum r/t hypertrophy
of circular pylorus muscle
- S&S usually start 2-4 weeks after birth
Diagnostic Assessment
Sonogram
UGI series
Blood studies to check for dehydration, lyte
imbalance, anemia
• Clinical Manifestations
Projectile vomiting
Chronic hunger/irritability
Weight loss
Dehydration
Distended upper abdomen
Olive shaped tumor in right upper quadrant
Gastric peristaltic waves from left to right
Decreased number of stools
Possible alkalosis
• Therapeutic Management
Surgery: pyloromyotomy where the circular muscle
fibers are released
Nursing Care
Pre-op
Post-op
Check I&O
Check VS; I&O
Restore hydration/lytes
Maintain IV’s
Check urine specific gravity
Monitor incision site
Monitor daily wt., N&V
HOB elevated
NGT
Initial feeds- clear liquids
Prevent infection
Tylenol for pain
Parental involvement
Parental support/reassurance
• Inflammatory Interferences
(Thrush, Peridontal disease, Gastritis)
Thrush (Candida Albicans): fungus infection of mucus membranes with
cheesy, white plaque
that looks like milk curds
-possible side effect of antibiotic use
Nursing Management
Mycostantin: swish and swallow
Good mouth care
• Peridontal Disease
Gingivitis: painful inflamed swollen gums r/t
inadequate dental care
-bleeding/ infection of gums
Nursing Care:
Promote proper oral hygiene
Routine flossing and dental visits
• Gastritis
Inflammation of gastric or stomach mucosa r/t
- inappropriate dietary intake (foods, alcohol)
- overuse of meds (ASA, NSAIDS)
- H. pylori bacteria
Assessment
-Nausea and vomiting
Abdominal discomfort
Anorexia
-Heartburn
-
Nursing Management
NPO with IV’s to maintain hydration/lyte balance
Non-irritating diet
Try to reduce anxiety
Meds
Antibiotics for H. pylori (Tetracycline)
H2 Receptor Antagonists (Zantac)
Proton Pump Inhibitor (Prevacid)
Cytoprotective: Sucrafate (Carafate) forms a
protective layer
• Traumatic Interferences with Nutrition
Facial Fractures: fractures of jaw/face requiring
wiring; trauma to facial bones
Nursing Interventions
Teeth are wired (upper/lower connected with
rubber bands to immobilize
Monitor N&V; dressings
Keep HOB elevated
Have suctioning available/scissors & wire cutters
High calorie liquid diet
Good mouthcare
• Poison Ingestion
Poison: any ingested substance that can cause
tissue destruction after coming in contact with
mucous membranes
Assessment
ABC’s
Check for: N&V;
abdominal pain
convulsions
change in LOC
decrease in pulse and respirations
Try to ID what was ingested and how much
• Management
Stabilize condition
ID toxic substance
Reverse its affects
Eliminate substance from the body
Support individual physically and psychologically
American Association of Poison Control Centers
1-800-222-1222
• Therapeutic Management
Elimination of poison: syrup of ipecac to induce
vomiting EXCEPT if it was a caustic (alkaline, acid,
petroleum distillate) product (mainly adults)
Doses: 6-12 months, 10 ml; DO NOT REPEAT
1-12 yrs, 15 ml; if no vomiting may repeat X1
>12 yrs. 30 ml; if no vomiting may repeat X1
Administer clear fluids (10-20ml/kg) after giving
ipecac
Therapeutic Management
• Gastric lavage: aspirate stomach contents and
wash out stomach in order to remove
substance or decrease absorption
•
•
Inactivate poison
Activated charcoal (30 – 50 grams):
binds with metabolite to prevent absorption
•
Antidotes: call poison control center
Practice Question
•
A client is being weaned TPN and is expected to take solid food today. The ongoing solution
rate has been 100 ml/ hr. A nurse anticipates that which of the following orders regarding
the TPN solution will accompany the diet orders?
•
•
•
•
A. discontinue the TPN
B. continue the current infusion rate orders for TPN
C. decrease TPN rate to 50 ml/ hr.
D. hang 1000 ml 0.9 % normal saline
Practice Question
•
A home health nurse provides instructions to the mother of an infant with cleft
palate regarding feeding. Which statement if made by the mother indicates a
need for further instructions?
–
–
–
–
A. “I will use a nipple with a small hole to prevent choking>”
B. “I will stimulate sucking by rubbing the nipple on the lower lip.”
C. “I will allow the infant time to swallow.”
D. “I will allow the infant to rest frequently to provide time to swallow
what has been placed in the mouth.”
Practice Question
• A five-month old girl is admitted with gastroesophageal
• reflux. Her signs and symptoms include emesis, poor weight gain,
irritability and gagging with feeds. The nurse would include which
intervention?
–
–
–
–
A. bi-weekly weights
B. urine dipstick each void
C. appropriate feeding position
D. monitor white blood count as indicator for infection