BACHELOR OF SCIENCE IN NURSING

OUTCOME BASED CLINICAL LEARNING 1

COURSE MODULE COURSE UNIT WEEK
1 2 11
DIGESTION

 Read course and unit objectives

 Read study guide prior to class attendance
 Read required learning resources; refer to unit terminologies for jargons
 Proactively participate in classroom discussions
 Participate in weekly discussion board (Canvas)
 Answer and submit course unit tasks.

Saunders Q & A Review for the NCLEX-RN Examination, 8th edition

Hinkle, Janice L. (2014)Brunner & Suddarth’s text book of Medical Surgical Nursing, 13 th. Philadelphia:
LippincottWilliams & Wilkins.617.0231 H592014

At the end of the course unit (CM), learners will be able to:

Cognitive:
1. Review on Gastro intestinal System
2. Discuss the process of Digestion and It’s importance
3. Identify the major function of the GI tract and organs
4. Identify signs and symptoms, management and diagnostic test for common Digestive problems

Affective:
1. Listen attentively during class discussions
2. Demonstrate tact and respect when challenging other people’s opinions and ideas
3. Accept comments and reactions of classmates on one’s opinions openly and graciously.
Psychomotor:
1. Participate actively during class discussions and group activities
2. Express opinion and thoughts in front of the class

GASTRO INTESTINAL SYSTEM

The Primary function of the alimentary tract is to provide the body with a continual supply of nutrients,
fluids and electrolytes for tissue nourishments.

 3 COMPONENTS:
1. A tract for ingestion and movement of food and fluids.
2. Secretion of digestive juices for breaking down the nutrients.
3. Absorption mechanisms for the utilization of foods, water and electrolytes for
continued growth and repair of body tissues.

DIGESTION
 Process of breakdown of food into smaller components that can be absorb into the blood.

GASTROINTESTINAL SYSTEM
 Responsible for the ingestion, digestion and absorption of nutrient and the elimination of waste
products of digestion.
 Anatomy and Physiology
System of organs in the body the take in food, digest it for the absorption of nutrients and
energy and expel waste material.

Upper GI tract
1. Mouth
2. Pharynx
3. Esophagus
4. Stomach
MAJOR FUNCTION OF THE G.I. TRACT
1. Ingestion
2. Digestion
3. Absorption
4. Excretion
MOUTH
1. Contains the lips, cheeks, palate, tongue, teeth, salivary glands, muscles and maxillary bones.
2. Saliva contains the enzyme amylase (ptyalin), which aids in digestion.

ESOPHAGUS
1. Collapsible muscular tube about 10 inches long.
2. Carries food from the pharynx to the stomach
STOMACH
1. Contains the cardia, fundus, the body and the pylorus
2. Mucous glands are located in the mucosa and prevent auto digestion by
providing an alkaline protective covering.
3. The lower esophageal (cardiac) sphincter prevents reflux of gastric contents into
the esophagus.
 4. The phyloric sphincter regulates the rate of stomach emptying into the small
intestine.
5. Hydrochloric acid kills microorganisms, breaks food into small particles, and
provides a chemical environment that facilitates gastric enzyme activation.
6. Pepsin is the chief coenzyme of gastric juice, which converts proteins into
proteases and peptones.
7. Intrinsic factors is necessary for the absorption of vitamin B12.
8. Gastrin controls gastric acidity.

SMALL INTESTINES
1. The duodenum contains the openings of the bile and pancreatic ducts.
2. The jejunum is about 8 feet long.
3. The ileum is about 12 feet long.
4. The small intestine terminates in the cecum.

LARGE INTESTINE
(Ascending, transverse, descending and sigmoid colon and rectum)
1. About 5 feet long
2. Absorbs water and eliminates waste
3. Ileocecal valve prevents contents of the large intestine from entering the ileum.
4. The internal and external anal sphincters control the anal canal.
5. The ileocecal valve prevents contents of the large intestine from entering the ileum.
6. The anal sphincter control the anal canal.

Peritoneum: Lines the abdominal cavity and forms the mesentery that supports the intestines and
blood supply.
ACCESSORY ORGAN
LIVER
1. The largest gland in the body, weighing 3-4 lbs.
2. Contains Kupffer’s cells, which remove bacteria in the portal venous blood.
3. Remove excess glucose, amino acids of fats.
4. Synthesizes glucose, amino acids and fats.
5. Aids in the digestion of fats, carbohydrates and protein.
6. Stores vitamins A, B, D and iron.

Hepatic Ducts
 Deliver bile to the gallbladder via the cyctic duct
 The common bile duct open into the duodenum with the ampulla of vater.
GALLBLADDER
1. Stores and concentrates bile and contents to force bile into the duodenum during the
digestion of fats
2. The cystic duct joints the hepatic duct to form the common bile duct
3. The sphincter of Oddi is located at the entrance to the duodenum.
Pancreas
Exocrine Gland:
a. Secrete sodium bicarbonate
b. Pancreatic juices that contain enzyme for digesting carbohydrates, fats and proteins.
Endocrine Gland:
a. Secrete glucagon to raise blood glucose
b. Secretes the Islets of Langerhans secretes insulin.
c. Insulin is secreted into the bloodstream and is important for carbohydrate metabolism.

SYSTEM ASSESSMENT:

INSPECTION:
1. Assess symmetry and contour standing and lying. (“pot-belly” is normal until
puberty).
2. Observe umbilicus for evidence of hernia.
3. Observe for visible peristaltic waves (often indicates obstruction).
4. Inspect area around anus for fissures or polyps. Inspect skin for diaper rash

AUSCULTATION: Be sure to do before palpation

1. Listen to all four quadrants.
2. High pitched, “tinkling” sounds indicative of diarrhea or gastroenteritis
3. Children’s bowel sounds often “hyperactive”

PERCUSSION:
1. Tympany normally heard throughout abdomen.
2. Dullness usually along right coastal margin to 1-3 cm below.
3. Dullness around symphysis pubis indicative of full bladder and is normal.

PALPATION:
1. Palpate last any areas identified as painful.
2. Ticklish children can place their hand under examiner’s to palpate.
 3. Spleen tip can be felt 1-2 cm below left costal margin during inspiration in infants
and young children.
4. Kidneys may be palpable in neonates, rarely in any other age group.
5. Sigmoid colon may be felt as tender, sausage-shaped mass.
6. Palpate for inguinal and femoral hernias.

Deep palpation of the abdomen is performed by placing the flat of the hand on the abdominal wall
and applying firm, steady pressure.
It may be helpful to use two-handed palpation.

PREPARATION
 Equipment - stethoscope, marking pen, ruler
 Empty bladder
 Short fingernails
 Warm and comfortable environment
 Patient lie on back, hands on the side or the chest, pillow under head, knees slightly
flexed or with rolled towel under the knees (dorsal recumbent position)

Assess for Hydration Status

1. Skin color, temperature, turgor, fontanelles.
2. Recent intake and output history
Assess for Nutritional Status:
1. Failure to gain weight- evaluate growth patterns on chart.
2. Abnormal stools, pattern, recent changes
3. Usual diet.

Abdominal distention can be caused by 3 factors:

1. Obesity – Abdomen is soft and rounded with a sunken umbilicus.
2. Ascites – Skin is shiny and glistening with an everted umbilicus. Veins are dilated and prominent
(more visible in thin, malnourished skin).
3. Obstruction – There may be visible, marked peristalsis; restlessness; lying with knees flexed;
grimacing facial expression; and uneven respirations.
ASSESMENT:

Abdominal distention

Endocrine gland
Production of hormone in islet of langerhans
1. A cells – Glucagon
2. B cells – insulin
3. Delta cells – somatostatin
Risk factors associated with the GI tract
1. Allergic reaction
2. Cardiac and respiratory & endocrine disorders
3. Chronic alcohol abuse, high stress levels, laxative use, aspirin and nonsteroidal anti-
inflammatory glands
4. Diabetes mellitus
5. Family history of GI disorders
6. Long term GI conditions
7. Neurological disorder
8. Previous abdominal surgery
9. Tobacco use
Diagnostic Studies
1. Upper GI tract study (barium swallow)
-examination of the upper GI tract under fluoroscopy after the client drinks barium sulfate.
Pre-procedure: NPO after midnight, the day of the test
Post procedure:
1. Laxative as prescribed
2. Instruct increase oral fluid intake to help pass the barium
2. Lower GI tract study (barium enema)
- A fluoroscopic and radiographic examination of the large intestine that is performed after rectal
instillation of barium sulfate.

Pre-procedure: Low fiber diet is given 1 to 2 days prior test

Clear liquid diet and laxative given night before the test
NPO after midnight the day of the test
Cleansing enema maybe prescribed on the morning og the test.
Post procedure:
1. Instruct increase oral fluid intake to help pass the barium
2. Mild laxative
3. Monitor stool for passage of barium

Upper GI endoscopy (Esophagogastroduodenoscopy (EGD)

With sedation, an endoscope is passed down the esophagus to view gastric wall sphinelous and
duodenum, tissue specimen can be obtained.
Preprocedure
1. NPO 6-12 hrs
2. Local anesthesia (spray)
3. Position left side to facilitate saliva drainage
Post procedure
1. NPO until gag reflex returns (1-2 hrs)
2. Monitor sign of perforation (pain, bleeding, unusual/difficulty in swallowing, elevated
temp)
Fiberoptic Colonoscopy
 To examine lining of the large intestine.
 Cardiac and respiratory function are monitored.
 Pre-procedure:
 Cleansing of the colon, Clear liquid diet a day before the test, NPO after midnight and
mild sedative is administered through IV.
 Post- Procedure:
 Bed rest until alert and monitor signs of bowel perforation and peritonitis.
Endoscopic Retrograde Cholangiopancreatography (ERCP)
-It examine hepatobiliary system (liver, pancreas, bile ducts and the gallbladder)
-Via flexible endoscope inserted into the esophagus to the descending duodenum
 With sedation
 Pre-procedure: NPO and sedation for several hours prior.
 Post- Procedure:
Monitor vital signs and return of gag reflex
Monitor signs of bowel perforation and peritonitis.
4. Endoscopic ultrasound
It provides image of the GI wall and digestive organs
 -Local anesthetic (spray)
 Pre-procedure: NPO and sedation for several hours prior.
 Post- Procedure:
Monitor vital signs and return of gag reflex
Monitor signs of bowel perforation and peritonitis.
Nursing procedures for GI system
1. Gastric and intestinal Decompression - Removal of fluid & gas to prevent gastric and
intestinal distention
2. Esophageal balloon tamponade – procedure done to control bleeding of ruptured
esophageal varices in patient with liver cirrhosis.
3. Enteral feeding – this may be nasogastric feeding or gastrostomy feeding
 a. NGT
b. Gastrostomy
c. PEG – percutaneous endoscopic gastrostomy
- commonly used method of nutritional support
4. Total parenteral nutrition (TPN)
- indicated in client who need extensive nutritional support over an extended period.
e.g. major GI disease, malnutrition, cancer

GI Medications
. Antacids
- drugs that interact with the gastric acids at the chemical level to neutralize them.
Common antacid OTC
1. Aluminum salts (hydroxide)
2. Calcium salts (carbonate)
3. Magnesium salts (milk of magnesia)
4. Sodium bicarbonate

Histamine (H2) receptor blockers “tidiness”

- these drugs block the release of hydrochloric acid in the stomach in response to gastrin
e.g. ranitidine, cimetidine, femotidine
Proton Pump Inhibitors “prazoles”
- these drugs suppress the secretion of hydrochloric acid into the lumen of the stomach.
-never agents for ulcer treatment
1. Omeprazole
2. Esomeprazole
3. Pantoprazole
4. Lansoprazole
Mucosal protectants
- these are agents that coat any injured area in the stomach to prevent further injury from acid.
1. Sucralfate (caralfate/ Iselpin)
Take sucralfate or empty stomach
2 hrs after meal
1 hour before meals

Common Gastrointestinal Disease

Gastritis
An inflammation of the stomach or gastric mucosa.
Caused by ingestion of food contaminated with disease-causing microorganism of food. Or overuse of
Aspirin or other (NSAID’s), excessive alcohol intake, bile reflux or radiation therapy.
 Chronic gastritis is caused by the bacteria H. pylori, and also by auto immune diseases, dietary
factors, medication, alcohol and smoking.
Peptic Ulcer Disease
Are sores that develop in the lining of the stomach, lower esophagus or small intestine (the
duodenum) usually as a result of inflammation caused by the bacteria H. pylori (helicobacter pylori), as
wall as the erosion from the gastric acid.
This is a common health problem.
3 Types of Peptic Ulcer
1. Esophageal ulcers – ulcers that develop inside the esophagus
2. Gastric ulcers – ulcers that develop inside the stomach
3. Duodenal ulcers – ulcers that develop in the upper section of the small intestine, called
duodenum.
Treatment of Peptic Ulcer
Both ulcers rely on antibiotics to lessen the number of H. Pylori
E.g. amoxicillin, clarithromycin, tetracycline.
Zantac – in case of hypersecretion of acid
- antacid are given to neutralize the acid of the stomach
- avoid foods the cause hyperacidity & irritation.
Appendicitis is an inflammation of the appendix.
-requires immediate surgery to remove the appendix.
-If left untreated, it will burst and spilling of infectious materials into the abdominal cavity.
This can lead to peritonitis, a serious inflammation of the abdominal cavity
-it is treated quickly with strong antibiotics (piperacillin/ tazobactam, imipenem, combination of
aminoglycosides and metronidazole.
GERD ( Gatroesophageal Reflux Disease)
Acid reflux leads to burning pain in the middle o the chest
-often occurs after meals or at night
Inflammatory Bowel Disease (IBD)
 Describes a group of disorders in which the intestines become inflamed.
 It is caused by autoimmune disease
TWO MAJOR TYPES OF IBD
1. Ulcerative colitis –colon or large intestines
2. Crohn’s disease - the mouth to the anus.
ASSESSMENT OF GASTOINTESTINAL SYSTEM
A. History
1. Medical History
a. Major illness and hospitalization
2. Diet History
a. usual foods and fluids that consumed
3. Family History
a. History of cancer, ulcer, colitis, hepatitis, obesity
 4. Psychosocial history and lifestyle
a. Occupation – meal times and travel

Critical to Remember:

1. Inspection
-Abdomen
-Inspect Umbilicus
-Note abdominal movements, pulsations, peristaltic movements

2. Auscultation
- Bowel sounds (5-30/mins)
- Note: Empty the bladder before auscultation

3. Percussion
-to determine the size & location of abdominal organs and to detect fluid, air and masses.
-percussion sounds over abdomen:
 Tympanic-high pitched, loud, musical over air
 Dull – thud like sounds over fluid or solid organs
4. Palpation
-palpate abdomen by lightly depressing (1-2 cm) the abdomen in quadrant to quadrant manner.
-Assess for masses, rebound tenderness, abdominal rigidity
-deep abdominal palpation should be performed cautiously only by skilled nurse.
TESTS FOR APPENDICITIS
 Blumberg’s sign
◦ Sharp, stabbing pain as the examiner releases pressure from the abdomen
 Rovsing’s sign
◦ Pain in the RLQ during pressure in the LLQ
◦ palpation of the left lower quadrant may produce tenderness and rebound
tenderness in the right lower quadrant in appendicitis (Rovsing's sign).
 Psoas sign
◦ Pain in the RLQ when raising the client’s right leg from the hip while applying
pressure on the lower thigh
 Obturator sign
◦ Pain in the RLQ when the hip and knee are flexed and when the legs are
rotated internally

McBurney’s point

Most important sign of acute appendicitis

DIGESTION- Process of breakdown of food into smaller components that can be absorb into the blood.
GASTROINTESTINAL SYSTEM- Responsible for the ingestion, digestion and absorption of nutrient
and the elimination of waste products of digestion

Saunders Q & A Review for the NCLEX-RN Examination, 8th edition

Hinkle, Janice L. (2014)Brunner & Suddarth’s text book of Medical Surgical Nursing, 13th. Philadelphia:
LippincottWilliams & Wilkins.617.0231 H592014

Berman, Audrey. Kozier, Barbara (Eds.) (2008) Kozier & Erb’s fundamentals of nursing: concepts,
process, and practice Upper Saddle River, N.J.:Pearson Prentice Hall, 10th edition
Borromeo, Annabelle R. et.al. (2014). Lewis's Medical-Surgical Nursing: Singapore: Elsevier Mosby.
617.0231 L58 2014, c3
Potter, Patricia A. et.al. ( 2017). Fundamentals of Nursing Vol.1, 9th ed. Singapore Elsevier
Science Direct. (2019). Nursing Process. Retrieved from science Direct:
https://www.sciencedirect.com/topics/nursing-and-health-professions/nursing-process Toney-Butler, T.
J., & Thayer, J. M. (2019). Nursing Process. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK49993

INDIVIDUAL TASK- 60 points

1. Make 3 Case scenario for clients with elimination disturbances and based on above scenario
develop an NCP Choose different cases for each scenario and formulate your NCP focusing
your priority problem (Peptic ulcer, Cirrhosis of the Liver, Appendicitis, Peritonitis, Ulcerative
Colitis etc.)