CHAPTER 14 GASTRO-INTESTINAL (DIGESTIVE) SYSTEM
Incredibly simplified, this system could be
described as one large tube that begins with the consuming of food at the
mouth and ends where it is fully processed and eliminated as stool. When food enters the oral cavity (mouth),
digestion is initiated. Food is then
processed with saliva and mastication (chewing), flows to the pharynx to the
esophagus via swallowing and peristalsis (an involuntary, wavelike muscular
movement to propel contents forward), where it eventually arrives at the
stomach.
While in the stomach,
muscular action and gastric juices further break down the food into a liquid
mass (chyme). Various substances, such as enzymes from the
pancreas, gallbladder, and liver are added as chyme flows to the small
intestines, again by peristalsis. In the
small intestines (where “small” denotes diameter and not length), nutrients are
microscopically absorbed. The
non-absorbed material is then propelled via peristalsis to the large intestines
or colon (large in diameter but not length compared to the small
intestine). The large colon takes out
all usable fluid to return it back to the body, and removes what the body cannot
utilize, waste, in the form of stool, which is excreted.
Some of the various
gastro-intestinal system conditions and care considerations that may be
experienced in the home-care setting appear below.
Colostomy: is a surgical procedure that takes a
piece of the large intestine and routes it through the abdominal wall via an
opening (stoma) outside the body. Stool
is then excreted via the stoma into a containing bag (appliance) outside the
body. This bypasses the normal defecation process, which would utilize the
entire large colon, rectum, and anus. The
farther (distal) part of the removed (resected) colon is closed and becomes
non-functional to allow healing to that site.
A colostomy can usually be performed at any area of the large colon, to
allow elimination of feces when the normal route is suspended due to severe
illness, infection, cancer, obstruction, perforation or any similar process
that requires the bowel to rest and heal.
A colostomy may be
temporary or permanent, depending on the underlying illness that requires this
intervention. Temporary colostomies are performed to allow
healing, for example, when a part of the large intestine has been removed
(resected) and requires rest. Once the two ends are appropriately healed, these
ends might be reattached to each other (anastomosis), and normal bowel function
may be achieved. However, permanent
colostomies are necessary at times.
Depending on the
location of the resection, and with bowel retraining, a new normal elimination
pattern can be resumed via the outside appliance, and with it, normal
functioning for the patient. If the location of the colostomy is at the
descending or sigmoid colon, a bowel training program may be undertaken to
evacuate the colon at a routine time.
This is called Bowel Irrigation.
Its purpose is to empty the colon of gas, mucus, and feces at daily
scheduled times to establish regularity and decrease elimination throughout the
day. This is achieved by instilling
fluids into the colostomy daily and at a consistent time to prompt
evacuation. It is not a guaranteed
procedure, but it has often been effective in providing learned evacuation,
depending on patient cooperation and reliability. Areas proximal (earlier on in the digestive
tract) have decreased bowel training possibilities. The area of the colon that is affected or
resected largely determines the success of bowel training.
Care
Considerations for Colostomies:
1) Bowel function
typically resumes 3 to 6 days post-surgery. The effluent (discharge) will initially be
liquid regardless of where the colostomy was placed. Continue with fluids, including water and
substances that provide electrolytes, as these will be lost in the effluent and
require replacement. Abstain from
alcohol, caffeinated beverages, and any liquids that have diuretic
actions.
2) Change in
effluent over time is typical and dependent on the colostomy site. A major function of the large intestine is to
remove water from processed food material and return it to the body. If a colostomy is performed close to the
small intestine, effluent will be liquid because the large intestine has had
minimal opportunity to recapture water.
The farther along in the digestive tract the colostomy is performed, the
more water is removed, and the stool becomes more formed. Generally, you can expect that if the
colostomy was performed in the transverse colon, because water remains in
the stool, the effluent will be soft, mushy and with potential irritation to
the stoma if leakage occurs. If the
colostomy is at the descending or sigmoid colon, effluent will be more
solid, since more fluid was extracted by the colon, and less irritating to the
stoma, because it is less liquid and irritating.
3) The stoma
requires constant assessment. The
stoma is made from a piece of the large intestine that is repositioned to
protrude above the skin surface. The
newly formed, surgically made stoma functions to eliminate waste via medical
equipment for containment rather than evacuation via the rectum and anus. The stoma should be assessed for irritation,
abrasions or trauma (excoriation) from dressings or effluent discharge. The stoma, itself, should be smooth, cherry
red, with a slight amount of edema. Discoloration,
excessive edema and discharge, signs of infection, fever, and foul smell may be
indications of decreases in stoma viability. Consult medical professionals.
4) Because of the
surgical manipulation and delicate tissue, this stoma site must receive the
utmost care. Gently cleanse with
mild soap and dry thoroughly. Apply the
drainage bag and adhesives ring so the fit is close to the stoma and makes a
firm seal to prevent leakage of effluent.
Watch for constricting the stoma, however. Use skin barriers before applying the drainage
bag and cover the skin around the stoma site.
But do not treat the stoma itself with any kind of barrier. These actions help to create seals, protect
surrounding skin, and ensure stoma remains intact, healthy, and
functional.
5) Application of
the bag requires time and patience to assure firm seal and smooth
application of drainage pouch. It takes
practice. Allow time to master this
task.
6) Bathing requires consideration and
preparation. Tape bag securely in
place to protect the stoma. Use mild
soap, rinse, and dry thoroughly without rubbing. Change the appliance after bathing. Always
protect the skin around the stoma, as well as the stoma itself, by cleansing
with a soft cloth and mild soap to remove the adhesives, intestinal enzymes and
fecal residual. If the stoma is placed in the upper colon, and once the site is
healed, consider placement of a tampon to temporarily contain fecal
discharge.
7) Monitor amount of
effluent and discharge contained in the appliance bag. Consider changing bag when it’s approximately
1/3 full or before the weight of the bag causes any separation.
8) Post-surgical diet will change over time. Initially, eat a low-fiber diet (includes
only cooked skinless vegetables – no salads and nothing raw; canned fruit;
juices without fiber; white refined flours, breads and pasta – no nuts, whole
grains, or seeds; lean proteins). Add
new foods gradually and observe effects.
Avoid anything that may cause gas, foul smells.
9) Assess and note changes in effluent. Soon after placement, there should be some
uniformity and consistency in the stool, dependent on details of the surgical
placement of the colostomy. Placement of
the colostomy dictates stool consistency.
As noted above, a stoma placed closer to the rectum will form more solid
stools and one farther from there will have stools that will be more liquid. Be aware of changes in stool color and
consistency outside of this norm.
Changes can be indications of potential problems with colostomy function
or with diet.
10) Assess
patient functional ability, willingness, and commitment to perform treatment. Motor skills and visual abilities are
necessary to provide stoma care and manipulate appliances. Proper skin care technique to the stoma and
surrounding tissue is essential. Home
situations should lend to privacy, especially if irrigation will be
completed. A separate bathroom is ideal,
allowing for privacy and unconstrained time, perhaps more than one-hour
uninterrupted time to fully complete bowel irrigation and evacuation.
11) Monitor and beware of nutrition. Fluid shifts are common leading to
dehydration. Foods, including vitamins
and medications, may be processed differently.
12) Body image and self-esteem are often
greatly diminished. Lack of such a
bodily function often leads to fear in social situations, embarrassment, and
decreased self-respect due to lack of bodily control. Reassure patient that with understanding,
patience, and obtaining a new normal, whether using a temporary or permanent
colostomy, life is usually impacted much less than is initially anticipated.
Dysphagia: is a term indicating difficulty
or inability to swallow. The act of
swallowing requires use of nerves as well as voluntary and involuntary muscles
associated with the jaw, tongue, pharynx, and esophagus. Dysphagia can occur for numerous reasons and
is often limited to affecting either the esophagus or the pharynx. Esophageal dysphagia affects
involuntary muscles and can be caused by spasms, narrowing of the esophagus
(esophageal strictures) which greatly slows forward progression of food,
tumors, and achalasia, in which the sphincter between the esophagus and stomach
doesn’t relax, resulting in actual trapping of food in the lower
esophagus. Pharyngeal dysphagia often
affects voluntary muscles, which may be damaged by neurological disorders,
such as Parkinson’s disease, multiple sclerosis, muscular dystrophy, or damage
from strokes, traumatic brain injuries, and spinal cord injuries. Complications of dysphagia include
malnutrition, weight loss, and dehydration.
However, often respiratory complications result when food enters the
pulmonary system via the trachea instead the esophagus. Aspiration pneumonia and respiratory
infections often result.
Care
Considerations for Dysphagia:
1) Evaluate ability to swallow effectively
prior to eating each meal. Check for
drooling, speech problems, and patient willingness. Lack of oral control can be an indicator for
aspiration potential. Verify patient
ability to cough on command. If
aspiration should occur, the gag reflex and coughing are essential to decrease
aspiration.
2) Food placement and patient positioning is
often critical to enhance swallowing effectiveness. Sit patient in upright position to increase
effect of gravity, as well as have patient tip head back when chewing and
swallowing. If dysphagia is due to a
neurological deficiency, then place food on the unaffected side of the mouth to
enhance chewing ability.
3) Mealtime often
becomes a chore for patients with dysphagia. The work required to eat, as well as changes
to diet, frequently eliminates satisfaction and enjoyment of this social
time. Suggest a swallowing technique
that includes gently placing the patient’s hand on the throat to feel the
action of swallowing. Feeling the motion
often leads to enhanced swallowing effort.
Additionally, sometimes swallowing two times in quick succession proves
effective. Decrease noise and
distractions to enhance the effort and concentration of eating. Provide coaching and verbal step-by-step
reminders for patients with neurological deficits. This might include: open mouth; feel food in
your mouth; chew food until the food is soft without big pieces; tilt head up;
swallow; swallow again, etc.
4) Food texture
plays an important role with dysphagia.
Liquids are often not given, as they are difficult to control in the
mouth, and along with solids, liquids pose the most aspiration threat. Often, the best consistency is that of mashed
potatoes, which can be controlled in the mouth and allow some chewing but can
also slide down the throat. This is
considered a puree diet which can be further categorized into thin, thick,
pre-mashed, or fork-mashed puree. The
diet selected by the physician will be dependent on the patient’s willingness
and ability.
5) Severe cases of dysphagia may require
procedures to widen the esophagus, for example, or placement of a feeding
tube when swallowing food or liquids poses a threat to patient’s safety, and/or
when malnutrition and fluid deficits are advanced. If a feeding tube is utilized, ensure that the
patient’s liquid diet is well balanced and provides all nutritional
requirements. Numerous types and selections are available. Keep records of all feedings, water, and
liquids that are given to the patient to ensure satiety, caloric intake, and
hydration. Monitor and clean the
feeding tube site as recommended by the physician. Be alert to leakage of stomach contents and
acids which are caustic to the skin.
Obtaining patient weight at frequent intervals is often recommended to
ensure too much weight isn’t lost or gained.
6) Understand that
eating provides not only nutritional benefits, but also social time and
personal pleasures. There are losses
associated with drastic diet changes.
The act of eating and chewing provides an individual release and satiety
that is often associated with shared personal experiences. With dysphagia, food consistencies are
usually altered to soft foods, often discouraging the eating of favorite foods
or eating from menu items. Eating
pleasures are initially considered restricted.
Understand that while these meal-time limitations may initially decrease
eating pleasure, social and basic satisfaction of the shared meal need not be
denied.
Altered Bowel Elimination: elimination
is simply the removal
(defecation) of waste products from the body via the large intestine. The product of defecation is stool. This is achieved by the coordinated efforts
of involuntary and voluntary muscular movements of the digestive system,
starting with eating and ending with defecating. Involuntary muscles, of which the individual
has no control, contract and relax to push contents (either food or stool)
forward by muscular action (peristalsis). Voluntary muscles, controlled by the
individual, allow for self-determined relaxation and contraction of sphincters
to finally release stool via the anus.
Individual elimination of stool varies and may occur once per day, a few
times daily, or once every other day.
What matters most is that an individual has consistent bowel movements
that are neither hard and require straining to expel, nor loose or watery
stool. Incidences of constipation or
liquid bowel movements should be addressed with a physician.
Often patients with ongoing care are prone
to bowel irregularities which may affect the quantity and/or quality of their
stool. Reasons for this include multiple
medications which can cause various gastrointestinal side-effects, restricted
mobility due to illness or injury, changes in eating habits or nutrition or
cognition impairments. This can range
from constipation to diarrhea, both of which are at opposite ends of the normal
bowel elimination spectrum.
Care
Considerations for Constipation:
1) It is often not easy to ascertain the
cause of constipation, which is a decrease in regularity, difficult passage
of hard, dry stool, and often with incomplete elimination of feces. Determining the cause not only helps to
select the best treatment option, it also aids in eliminating ongoing
constipation patterns.
2) Medications often
cause constipation. Pain-relieving
drugs, such as opiates, so frequently cause constipation that it’s common that
a mild stool softener or laxative is suggested when these drugs are
prescribed. Anti-depressants and some
cardiac drugs can also affect bowel elimination. Because these medications are usually
prescribed long-term, artificial measures to resolve constipation should be as
minimal as possible due to the potential negative long-term effects of laxative
use.
3) Some disease
processes can contribute to constipation.
Hypothyroidism or other metabolic disorders can decrease functionality
of the bowels. A chronic heart failure
patient often has fluid intake restrictions which could lead to hard stools
that are difficult to pass. Patients may
exhibit gastrointestinal uniqueness such as slow transit constipation (a
process in which peristalsis is slower than normal), have a longer than usual
colon with overlapping segments (redundant colon) or may have a colon that
anatomically twists and turns more than usual making stool passage
difficult. Ensure constipation issues
are discussed with the physician and follow appropriate guidelines.
4) Constipation due
to lack of fiber can easily be resolved.
Dietary fiber adds bulk to stool to aid passage through the large
intestine because bulk doesn’t fully digest.
Most plant foods have both soluble and insoluble fiber. An additional benefit of insoluble fiber is
that stool also retains some water, which helps to keep stool soft for easier
passage. However, fiber can also be
added to a diet by using over-the-counter fiber supplements, such as Citrucel
or Metamucil for example. These
capsules, or powders added to fluid, taken daily can increase fiber intake. Supplements are often used for a patient who
is unable to eat or for individuals that can’t or won’t increase dietary fiber
due to the increase of food that is required or from distaste of food that
provides it.
5) A major function
of the large intestine is to retrieve and return fluid from waste back to the
body for use. When there is
insufficient fluid intake, more water is removed from waste. Feces then become harder, more difficult, and
perhaps more painful to pass. This all
leads to increased risk for constipation. Fluid should be drunk often. There is no standard amount to drink, but a
rule of thumb is that when one feels thirsty, one is already exhibiting signs
of fluid dehydration. Decrease
caffeinated beverages such as coffee, tea, and cola. Juices increase fluids but
also increase sugar. Water is often the
preferred beverage to consume.
6) Sedentary lifestyle, often the case for a
home-care patient, contributes greatly to constipation. The elimination of feces is largely
controlled by involuntary muscular movements.
When the body remains at rest, the body minimizes metabolism,
peristalsis decreases, and bodily functions revert to a lower level of
expenditure and usage. Simple movement,
such as walking, promotes increased involuntary muscular functions, as well as
all the additional health benefits associated with exercise. In addition, when one is sedentary, food
consumption that maintained a normal weight may now be more caloric than is
necessary. A sedentary patient may also
experience boredom. Often, eating
resolves that emotional feeling. Unfortunately,
the snacks desired are usually those that do not provide increased fiber to the
diet. For a bed-ridden patient, range
of motion exercise decrease sustained loss of muscle mass. Decreasing the amount of caloric intake, as
well as increasing fluids, should be considered.
7) Various types of over-the-counter
laxatives are available to help resolve constipation. However, they may have side effects such as
bloating, gas, or cramping for example.
Stool softeners, such as Colace (docusate sodium) or Miralax (glycolax),
increase water in the bowels. With the
additional water, stools pass more easily and without a great amount of
strain. The additional fluid also helps
to promote and stimulate bowel movements.
These medications do not damage the normal action of the colon and are
not addicting. Other laxatives, such as
Senokot (senna) and Dulcolax enhance the action of the large intestine to
increase forward movement and release of stool.
This works to promote the large intestines’ normal function. Because this is artificially increasing the
colon’s peristalsis, long term use could be detrimental. Therefore, these, and any other laxative
assisting medications should be used as infrequently as possible. Another type of laxative is to be used
infrequently and with physician consult: saline laxatives take fluid from the
body, due to their composition, and return it to the colon. However, with the fluid, essential
electrolytes necessary for cardiac function, for example, are also
removed. These laxatives are often
prescribed as bowel prep for testing and procedures, such as a colonoscopy when
the colon needs to be free and clean of all feces. Before administering, consult with the
patient’s physician.
8) Digital disimpaction may be necessary at
times when previous methods to resolve constipation are ineffective. This procedure is often both embarrassing and
uncomfortable to the patient. It also
has adverse complications, such as vagal nerve stimulation, which decreases
heart rate. Additionally, the digital
irritation can cause bleeding as well as discomfort in passing stool. A gloved hand with a lubricated finger is
inserted into the anus to gently but firmly remove stool from the rectum. Often that will stimulate a bowel
movement. If it doesn’t, stool removal
may provide some relief for the patient.
9) Enemas, inserted into the anus to provide
lubrication up to the rectum, are used break up stool for elimination. They are used as a last effort to relieve
constipation, partially due to the discomfort and embarrassment they may
cause to the patient. However, they are
also detrimental to the body as they disrupt the normal bodily process and
cause dependence. Frequent use of enemas
causes shut-down of effort, and just a few usages sometimes decreases the
body’s ability to normally expel feces. Enemas
should only be used when all other interventions fail to evacuate the
patient’s bowel. For an enema using
small amount of fluid, place the patient on the left side with right leg over
the left for support and both knees flexed to chest. Ensure towels, bedpan, and cleaning items are
readily available. Have the patient
breathe out though the mouth, which helps to relax the external sphincter. Assess for hemorrhoids that could decrease
visual ability for placing the enema tube and/or increase risk for
bleeding. Lubricate tip of enema tube,
separate buttocks, and insert tip of enema tube into the anus to instill
fluid. The fluid should be retained for
a period as indicated per package or physician instructions for best
results. When the process is complete
according to directions, provide full and gentle hygiene to the genitourinary
and anal areas. Be aware that
embarrassment and apprehension may be more paramount than the actual discomfort
of the process. Provide gentle care
and explain procedural details throughout the process.
Care
Considerations for Diarrhea:
1) Diarrhea is the
presence of unformed stools that may be loose to watery that occur
frequently and are unusual for the patient.
Besides the loss of water that is unable to be recaptured normally by
the large intestine, essential electrolytes are lost. Ultimately, the patient may exhibit
dehydration, heart arrhythmias when the condition is long-lasting, and skin
breakdown from recurrent presence and cleaning of stool. This condition can be caused, for example, by
diet, infection, food consumption, or medications.
2) Cause needs to be
determined. Due to the rapid passing
of the stools through the large colon, there is insufficient time for the colon
to return water from stools back to the body.
When water is not recovered by the colon, other essential chemicals,
such as electrolytes which aid in cardiac function, are also lost. Look for dietary changes, gastrointestinal
infections, additions of medications such as antibiotics, and changes due to
traveling.
3) Diarrhea may be caused by recent
administration of antibiotics which destroy the normal flora of the GI tract. Often administration of yogurt or other
over-the-counter probiotics will help remedy this cause.
4) Dehydration is often exhibited. Headaches, decreases in consciousness,
decreases in urinary output, and hyperventilation (increased rate of breathing)
often occur. Fluid intake needs to
offset the fluid lost due to diarrhea.
Consult physician should any of these be noted.
5) Assess the stool for consistency, color,
and volume. This should also be
reported to the physician.
6) Skin breakdown is common with diarrhea. Check the outer skin for any signs of
breakdown such as non-blanchable skin, lack of normal skin tension, or
discoloration. Separate the buttocks to
view the anus and inner-lying areas for excoriation, abrasions, redness,
irritation, or breakdown. Wash and dry
gently in a patting motion – do not rub.
Apply protective ointments such as A+D Ointment.
7) Anti-diarrheal medications can be given
but caution should be used to ensure their administration does not cause
constipation. Home and
over-the-counter remedies include strong tea, rice, whey, Pepto-Bismol. When bouts of diarrhea have decreased, resume
the normal diet slowly to further calm and allow healing of the irritated
intestinal mucosa (lining) until fully healed.
###
Contact information:
Diane R. Beggin, RN
40 Sycamore Drive
Montgomery, NY 12549
Web site: http://ManageNursingCareAtHome.com
Book: HOW TO MANAGE NURSING CARE AT HOME, by Cooper and Beggin
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