The Gastrointestinal

System

GASTROINTESTINAL CHANGES ASSOCIATED

WITH AGING

Begin before age 50

Changes in the mouth

Decreased esophageal motility
Reduced peristalsis
Diminished ability of gastric mucosa to resist damage
Decreased production of intrinsic factor
Reduced intestinal absorption and blood flow
Intrinsic factor (IF) also known as gastric intrinsic factor (GIF) is a glycoprotein produced
by the parietal cells of the stomach. It is necessary for the absorption of vitamin B12 later on in
the terminal ileum

FIGURE 20-1
NORMAL CONFIGURATION OF THE GI TRACT.

GASTROINTESTINAL CHANGES ASSOCIATED

WITH AGING

Begin before age 50

Decreased pancreas size
Increased incidence of cholelithiasis, decreased
production of bile synthesis
Decreased liver size and blood flow
Decreased thirst and hunger
Increased medication use

AGING AND THE GASTROINTESTINAL SYSTEM

Aging has limited impact on system
Aging associated with increased prevalence of
many GI disorders
Evaluate disorders closely

FIGURE 20-2
NORMAL CHANGES

OF AGING RELATED TO THE GASTROINTESTINAL TRACT.

DYSPHAGIA
Number-one esophageal disorder in older people
Impacts oral intake
Seen in 50% of institutionalized persons

DYSPHAGIA

Causes
Poor tongue control
Poor preparation of food bolus for swallowing
Poor dentition: pertains to the development of teeth and
their arrangement in the mouth
Lack of saliva

DYSPHAGIA

Signs and symptoms

Reports of difficulty swallowing
Difficulty controlling food or saliva in mouth
Facial droop
Dementia, frailty, confusion
Inability to sit upright

DYSPHAGIA

Signs and symptoms

Choking or coughing while eating
Increased oral or nasal congestion after meals
Weak voice or slurred speech
Recurrent upper respiratory infections
Unexplained weight loss

10

DYSPHAGIA

Risk factors

Incorrect positioning
Inappropriate intake
Rapid feeding
Older persons labeled as difficult

Comorbidities
Neurological disorders
Muscular disorders
Anatomical abnormalities

11

DYSPHAGIA

Nursing assessment

Observation of individual during eating and drinking

12

DYSPHAGIA

Nursing assessment

Question patient concerning

Choking
Dry mouth
Excess saliva
Inability to control food in mouth
Spitting up after meals
Need to frequently clear throat
Difficulty sitting up during mealtimes

13

DYSPHAGIA

Nursing interventions
Minimize distractions while eating
Use consistent feeding techniques
Proper positioning during mealtime
Monitor respirations during feeding
Provide oral hygiene before and after eating
Offer intake consistencies as recommended
Do not forcefully feed

14

GASTROESOPHAGEAL REFLUX DISEASE

Caused by weakness of esophageal sphincter
Increased incidence of hiatal hernia
Risk factors

Aging
Thyroid disease
Scleroderma or connective tissue disorders
Diabetes

15

GASTROESOPHAGEAL REFLUX DISEASE

Risk factors

Aging
Thyroid disease
Scleroderma or connective tissue disorders
Diabetes

16

GASTROESOPHAGEAL REFLUX DISEASE

Signs and symptoms

Heartburn
Indigestion
Belching:(also known as burping, ructus, or eructation) involves the
release of gas from the digestive tract (mainly esophagus and stomach)
through the mouth.

Hiccups
Regurgitation of gastric contents
Voice hoarseness

17

GASTROESOPHAGEAL REFLUX DISEASE

Triggers
Eating large meals
Certain medications
High-fat foods
High caffeine intake
Alcohol and tobacco use
Reclining after eating
Obesity

18

GASTROESOPHAGEAL REFLUX DISEASE

Consequences for GERD
Nursing assessment of GERD
Diagnostic testing

Barium swallow
Endoscopy
Esophageal contents pH

19

GASTROESOPHAGEAL REFLUX DISEASE

Goals of treatment

Symptom control
Heal mucosal injury

20

GASTROESOPHAGEAL REFLUX DISEASE

Lifestyle modifications

Elevate head of bed

Reduce portion size
Avoid trigger foods
Drink 6 to 8 ounces of water with medications

21

GASTROESOPHAGEAL REFLUX DISEASE

Lifestyle modifications
Report all medications to physician
Avoid tight-fitting clothes and girdles(belt-shaped textile)
Remain upright after meals for 1 to 3 hours
Avoid right side-lying position
Stop smoking

22

GASTROESOPHAGEAL REFLUX DISEASE

Medications
Antacids
Aluminum-containing antacids
Histamine 2 receptor agonists
Proton pump inhibitors
Combination drugs

Surgery

23

GASTRIC DISORDERS

Gastritis

Inflammation of the gastric mucosa

Classification
Severity
Site involvement
Inflammatory cell type

Diagnosis

Endoscopy

24

GASTRIC DISORDERS

Gastritis

Treatment
Reducing contributing factors
Acid neutralization and suppression
Protection of gastric mucosa
Antibiotic therapy
Transfusions as needed

25

GASTRIC DISORDERS

Peptic and duodenal ulcer disease

An excoriated area of the gastric mucosa

Signs and symptoms
Bleeding
Positive fecal occult blood test
Pain

Diagnosis
H. pylori breath test
Endoscopy

26

GASTRIC DISORDERS

Peptic and duodenal ulcer disease

Treatment
Discontinue use of NSAIDs, alcohol, tobacco, and caffeine
Small, frequent meals
Medications

27

GASTRIC DISORDERS

Zollinger-Ellison syndrome

Caused by a gastrin-producing tumor

Characterized by gastric hypersecretion and peptic
ulceration
Treatment may include tumor removal and surgical
resection

28

GASTRIC DISORDERS

Gastric volvulus

Turning, twisting, or telescoping of the stomach onto or

into itself
Symptoms
Acute pain
Shock and hypotension
Abdominal distention
Inability to vomit
Dyspnea

29

LOWER GASTROINTESTINAL TRACT

DISORDERS

Diverticular disease
Saclike mucosal projections protrude through muscular
layer of GI tract
Projections may trap feces resulting in inflammation,
infection, and rupture
Seen most in sigmoid and descending colon

30

LOWER GASTROINTESTINAL TRACT

DISORDERS

Diverticular disease

Risk factors
Physical inactivity
Constipation
Obesity
Smoking
NSAID therapy

Management

Increase fiber intake

31

LOWER GASTROINTESTINAL TRACT

DISORDERS

Diverticulitis

Normal bowel flora and fecal material becomes trapped

in pouches resulting in inflammation, infection, and
obstruction
Signs and symptoms
Fever
Leukocytosis
Pain or abdominal tenderness

32

LOWER GASTROINTESTINAL TRACT

DISORDERS

Assessment of diverticular disease

Physical examination
Questions regarding bowel history

Diagnosis
Abdominal CT scan
Ultrasound

33

LOWER GASTROINTESTINAL TRACT

DISORDERS

Goals of treatment

Eliminate bacterial infection

Liquid diet advancing to low fiber to allow colon to rest

34

INFLAMMATORY BOWEL DISEASE

Ulcerative colitis

Chronic inflammatory process

Impacts superficial layers of colon walls
Wide spread ulceration of colon walls
Signs and symptoms
Bloody diarrhea
Lower left quadrant abdominal pain
Weight loss

35

INFLAMMATORY BOWEL DISEASE

Ulcerative colitis

Diagnosis
Sigmoidoscopy
Colonoscopy
Rectal mucosa biopsy
Stool specimens

Treatment
Oral corticosteroids
5-ASA drugs
Surgery

36

INFLAMMATORY BOWEL DISEASE

Crohns disease
Chronic inflammatory disorder of the terminal ileum or colon
Characterized by inflammation, linear ulcerations, and
granulomas
Signs and symptoms

Diarrhea
Fever
Abdominal pain
Weight loss

37

INFLAMMATORY BOWEL DISEASE

Crohns disease

Diagnosis
Abdominal CT scan
Complete blood cell count
Barium enema colonoscopy

Treatment
Oral corticosteroids
Surgery

38

BENIGN AND MALIGNANT TUMORS

Benign tumors or polyps seen in 75% of persons
over age 50
Predisposing factors

Age
Diet
Family history
Prior diagnosis polyps

39

BENIGN AND MALIGNANT TUMORS

Malignant tumor

2nd most common malignancy in the United States

Increase incidence with age
Predisposing factors
Family history
Inflammatory bowel disease
History of colorectal tumors

40

BENIGN AND MALIGNANT TUMORS

Malignant tumor

Signs and symptoms

Change in bowel habits
Abdominal pain
Abdominal mass
Anemia
Rectal bleeding
Weight loss

41

BENIGN AND MALIGNANT TUMORS

Malignant tumor

Diagnostic testing
Colonoscopy
Carcinoembryonic antigen levels
Sigmoidoscopy
Fecal occult blood testing

Treatment

Surgical resection

42

ANTIBIOTIC THERAPY ASSOCIATED DIARRHEA

AND COLITIS
Occurs during or shortly after administration of
antibiotics
Caused by Clostridium difficile cytoxin, causing
bowel inflammation and epithelial necrosis resulting
in diarrhea and postmembranous colitis

43

ANTIBIOTIC THERAPY ASSOCIATED DIARRHEA

AND COLITIS

Signs and symptoms

Watery, nonbloody diarrhea

Low abdominal pain
Fever

Potential complications
Dehydration
Hypotension
Colonic perforation

44

ANTIBIOTIC THERAPY ASSOCIATED DIARRHEA

AND COLITIS

Diagnosis

Stool perforation

Treatment
Metronidazole
Vancomycin

45

CONSTIPATION

Definitions
Infrequent defecation
Hardened or reduced caliber of stool
Sensation of incomplete evacuation or need to strain
with stools
Three bowel movements or less per week

46

CONSTIPATION

Predisposing factors
Aging
Certain medications
Metabolic and endocrine disorders
Muscular dystrophy
Neurologic disorders
Recent abdominal surgery
Obstructive disorders

47

CONSTIPATION

Complications

Abdominal discomfort
Loss of appetite
Nausea and vomiting
Excessive straining

Hemorrhoids, anal fissures, and rectal prolapse

Intestinal obstruction
Colonic ulceration
Overflow incontinence with stool leakage

48

CONSTIPATION

Assessment

Evaluate complaint
Management
Education
Hydration
Increased mobility
Fiber supplementation

49

CONSTIPATION

Assessment

Management

Medication
Bulk laxative
Stool softeners
Osmotic laxatives
Magnesium containing laxatives
Senna
Suppositories and enema

50

DIARRHEA

Defined as abnormally loose stool accompanied by

change in frequency or volume

51

DIARRHEA

Causes
Virus
Food poisoning
Food contamination
Medications
Lactose intolerance

52

DIARRHEA

Symptoms
Urgency
Cramping
Bloating
Incontinence
Pain on defecation
Presence of blood in stool

53

DIARRHEA

Assessment

Interview
Physical examination

Management
Antidiarrheal agents
Soluble fiber

54

FECAL INCONTINENCE
Seen in 50% of institutionalized elderly
Cause

Mobility problems
Severe depression
Cognitive impairment

55

HEMORRHOIDS AND RECTAL BLEEDING

Hemorrhoids and colorectal cancer most common
causes of rectal bleeding
Hemorrhoids are varicose of anorectal junction
Treatment based upon size

56

LIVER AND BILIARY DISORDERS

Signs and symptoms

Older adults often present with vague, ambiguous
symptoms
Fatigue
Weight loss
Anorexia
Malaise

57

LIVER AND BILIARY DISORDERS

Risk of disease increases with aging
Hepatitis A
Hepatitis B
Hepatitis B and C
Hepatic cysts

Common in older adults

Typically benign

58

LIVER AND BILIARY DISORDERS

Hepatic cysts

Common in older adults

Typically benign

59

LIVER AND BILIARY DISORDERS

Metastatic carcinoma

Most common liver cancer

Highest rates in those aged 5070
Associated with alcohol and tobacco use

60

LIVER AND BILIARY DISORDERS

Metastatic carcinoma

Signs and symptoms

Jaundice
Variceal bleeding
Ascites
Right upper quadrant pain
Weight loss
Enlarged liver

61

LIVER AND BILIARY DISORDERS

Metastatic carcinoma

Diagnostic tests
Liver function tests
Abdominal ultrasound
CT scan
Liver biopsy

Treatment based upon tumor stage and patients health

status

62

LIVER AND BILIARY DISORDERS

Gallstones

Increased incidence with age

1:3 people over age 70 have gallstones
Symptoms
Right upper quadrant pain
Gas
Distention
Nausea and vomiting

63

LIVER AND BILIARY DISORDERS

Gallstones

Diagnostic testing
Abdominal CT scan
Ultrasound

Treatment
Laparoscopic cholecystectomy
Pharmacological dissolution
Extracorporeal shock wave lithotripsy
Dietary modifications

64

LIVER AND BILIARY DISORDERS

Pancreatitis

Acute pancreatitis

Symptoms
Epigastric pain
Nausea and vomiting
Elevated serum liver function studies

Amylase
Lipase
Bilirubin
Alkaline phosphatase

65

LIVER AND BILIARY DISORDERS

Pancreatitis

Acute pancreatitis

Treatment
Nasogastric suction
Pain management
Hyperalimentation
Fluid replacement

66

LIVER AND BILIARY DISORDERS

Pancreatitis

Chronic pancreatitis
Symptoms
Weight loss
Diarrhea
Diabetes
Persistent pain
Treatment
Behavior modification
Surgery

67

MEDICATIONS WITH POTENTIAL TO AFFECT

THE GASTROINTESTINAL TRACT

Anticholinergics

Antidepressants
Neuroleptics
Antihistamines
Antiparkinsonian agents

68

MEDICATIONS WITH POTENTIAL TO AFFECT

THE GASTROINTESTINAL TRACT

Antihypertensives

Calcium channel blockers

ACE inhibitors
Diuretics

Iron and calcium supplements

Aluminum-containing antacids
Opiates
Laxatives

69

MEDICATIONS AS RISK FACTORS FOR

ESOPHAGEAL INJURY
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Potassium chloride
Tetracycline
Quinidine
Alendronate
Ferrous sulfate
Theophylline

70

RISK FACTORS FOR DYSPHAGIA IN

INSTITUTIONALIZED OLDER PERSONS
Inappropriate positioning for mealtimes
Inappropriate feeding of foods and liquids

Thin food and liquids difficult to swallow

Thickened liquids slow the swallow process

Too-rapid feeding of at-risk patients

Residents labeled as difficult or uncooperative

71

GERD RISK FACTORS

Primary

Length and frequency of esophageal acid exposure

Others
Thyroid disease
Diabetes
Scleroderma
Connective tissue disorders

72

RISK FACTORS FOR LARGER ULCERS

Higher doses of NSAIDs
History of peptic ulcer disease
Concurrent use of anticoagulants

73

LIFESTYLE FACTORS CONTRIBUTE TO RISK

OF DIVERTICULOSIS

Inadequate dietary fiber intake

74

PREDISPOSING FACTORS FOR BENIGN

TUMORS
Age
Diet
Family history
Prior diagnosis of polyps

75

C. DIFFICILE-INDUCED DIARRHEA AND COLITIS

Recent surgery
Nasogastric or gastric intubation
Antibiotics
Common in older persons receiving treatment in
hospitals or residing in nursing homes

76

DRUGS COMMONLY ASSOCIATED WITH

DIARRHEA
Nonsteroidal anti-inflammatory drugs (NSAIDs)
Magnesium-containing antacids
Antiarrhythmics
Beta-blockers
Quindine
Colchicines
Digoxin

77

RISK FACTORS FOR CONSTIPATION

Dehydration
Side effects of medications

Anticholinergic side effects

Antidepressants
Neuroleptics
Antihistamines
Antiparkinsonian agents

78

RISK FACTORS FOR CONSTIPATION

Side effects of medications

Selected antihypertensive agents

Calcium channel blockers
ACE inhibitors
Diuretics

79

RISK FACTORS FOR CONSTIPATION

Side effects of medications

Iron supplements
Calcium supplements
Aluminum-containing antacids
Benzodiazepines
Antiarrhythmics
Opiates

80

RISK FACTORS FOR CONSTIPATION

Insufficient fiber intake
Cognitive impairment and immobility
Physical illness

Metabolic/endocrine disorders
Muscular dystrophy
Neurological disorders
Recent abdominal surgery
Obstructive disorders

81

RISK FACTORS FOR FECAL INCONTINENCE

Dementia
Depression
Chronic pain
Lack of mobility
Lack of sensation

82

FACTORS THAT INCREASE RISK FOR

PANCREATITIS
Gallstones
Hyperlipidemia
Hypercalcemia

83

FACTORS THAT INCREASE RISK FOR

PANCREATITIS

Medications

Estrogen
Furosemide
ACE inhibitors
Mesalamine

Alcohol abuse
Cancer

84

PRESENTATION OF GI DISORDERS IN THE

OLDER ADULT
Present with different symptoms than the younger
adult
Peptic ulcer disease

Impaired visceral pain perception

Longer to recognize and report pain

Symptoms for gastric disorders tend to be vague

Symptoms may be attributed as a normal agerelated change

85

OTHER DISORDERS RESULTING IN GI

SYSTEM CHANGES
Diabetes
Neurological illness
Vascular disorders

86

PATIENT EDUCATION NEEDS

Presentation and reporting of symptoms of GI
problems in the older adult
Impact of select medications on the GI system
Safe and appropriate use of prescribed mediations
Recommended health screenings for the GI system

87

LIFESTYLE MODIFICATION FOR GERD

Lose weight as appropriate
Avoid tight clothing
Remain in upright position after eating
Reduce alcohol, caffeine, and fat intake

88

NURSING DIAGNOSES FOR PATIENTS WITH

GERD
Impaired swallowing
Impaired skin integrity
Impaired social interaction (if appropriate)
Sleep pattern disturbance (if appropriate)
Acute or chronic pain

89

LIFESTYLE MODIFICATION FOR

PEPTIC/DUODENAL ULCER DISEASE
Discontinue use of all NSAIDs
Discontinue use of alcohol, tobacco, and caffeine
Avoid offending foods

90

LIFESTYLE MODIFICATIONS TO PREVENT

DIVERTICULITIS AND MANAGE DIVERTICULAR
DISEASE
Increase dietary fiber
Drink at least 8 full glasses of water per day (unless
contraindicated by other medical condition)
Do not ignore the urge to have a bowel movement
Exercise regularly
Avoid foods that precipitate painful attacks

91

EARLY DETECTION AND PREVENTION OF

COLON CANCER
Annual fecal occult blood testing
Colonoscopy and sigmoidoscopy screenings

Initially begin with sigmoidoscopy

Colonoscopy screening should begin at age 50

92

NURSING MANAGEMENT OF CONSTIPATION

Patient education

Dietary intake of fluid and fiber

Exercise
Awareness in bowel habits
Understanding of potential impact of selected
medications

93

INTERVENTIONS TO PREVENT ASPIRATION

Minimize distractions during eating
Provide a pleasant mealtime environment
Use consistent feeding techniques
Document patient food preferences and
consumption patterns
Position patient upright during and 1 hour following
mealtime
Allow time for swallowing

94

INTERVENTIONS TO PREVENT ASPIRATION

Monitor respirations
Provide oral hygiene before and after mealtimes
Provide meals when patient is rested
Provide food and fluid of appropriate consistencies

95

INTERVENTIONS TO PREVENT ASPIRATION

Never force-feed
Monitor weight, function status, and patient
satisfaction during meals
Evaluate swallowing capacity every 6 months and
prn
Avoid nasogastric tubes

96

NURSING DIAGNOSES FOR PATIENTS WITH

DYSPHAGIA
Impaired Swallowing
Feeding Self-Care Deficit
Risk for Fluid Volume Imbalance (Deficit)
Ineffective Airway Clearance
Risk for Aspiration
Altered Dentition (if appropriate)

97

RELATED FACTORS IDENTIFIED BY NANDA IN

2003
Neuromuscular impairment
Decreased strength or excursion of muscles
involved in mastication
Perceptual impairment

98

RELATED FACTORS IDENTIFIED BY NANDA IN

2003
Mechanical obstruction (edema, tracheostomy tube,
tumor)
Fatigue
Limited awareness
Reddened, irritated oropharyngeal cavity

99

AGGRESSIVE NURSING INTERVENTIONS TO

PREVENT DEHYDRATION
Frequently assess pulse and blood pressure
Establish schedule to offer fluids every 15 to 30
minutes
Measure intake and output
Assess skin turgor
Notify primary care provider if dehydration is
imminent

100

NURSING INTERVENTIONS FOR FECAL

INCONTINENCE
Regular toileting program
Administration of high-fiber diet
Elimination of medications associated with diarrhea
Treatment of infections

101

ENDOSCOPIC GASTROINTESTINAL
PROCEDURES

Esophagogastroduodenoscopy

Restrict intake prior to procedure

Strong laxative
Antibiotics for patients at high risk for infection
Oxygen during tube insertion

Sigmoidoscopy
Sedation not required
Phosphate enemas

102

ENDOSCOPIC GASTROINTESTINAL
PROCEDURES

Colonoscopy

1 to 2 days of liquid diet

Cathartic evening prior
Monitor patients with cardiovascular or renal instability

103

NURSING DIAGNOSES ASSOCIATED WITH

GASTROINTESTINAL TRACT PROBLEMS
Imbalanced Nutrition: Less Than Body
Requirements for those with anorexia
Risk for Infection, for those undergoing endoscopic
examination and needing antibiotic prophylaxis
Constipation and Perceived Constipation
Diarrhea
Bowel Incontinence

104

NURSING DIAGNOSES ASSOCIATED WITH

GASTROINTESTINAL TRACT PROBLEMS
Risk for Constipation
Ineffective Tissue perfusion: Gastrointestinal Tract
Risk for Aspiration
Impaired Oral Mucous Membrane
Social Isolation (if appropriate)
Noncompliance (if appropriate)

105

NURSING DIAGNOSES ASSOCIATED WITH

GASTROINTESTINAL TRACT PROBLEMS
Ineffective Breath Maintenance
Toileting Self-Care Deficit
Acute or Chronic Pain Disturbance
Nausea

106