Anatomy and physiologi pf the digestive tract

The functions of the digestive tract are ingestion, digestion, and absorption of nutrients, and
elimination of wastes. Digestion is the breakdown of food into simple nutrient molecules that can be
used by the cells. The process of digestion requires (1) the adequate intake of food and fluids, (2) the
mechanical and chemical breakdown of food, and (3) the movement of food through the digestive
tract. Absorption is the transfer of digested food molecules from the digestive tract into the
bloodstream. Elimination is the removal of solid food wastes from the body

The digestive tract is also called the gastrointestinal (GI) tract and the alimentary tract
(figure 38-1). A muscular tube about 30 feet long. The main parts of the digestive tract are the
mouth, pharynx, esophagus, stomach, small intestine, large intestine, and anus.

Other organs that are outside the digestive tract but are considered part of the digestive
system are called accesddory organs. Accsessory organs include the salivary glands, liver, galbladder,
and pancreas. Each of the secretes fluid, containing specialized enzymes, into the digestive tract.
These enzymes play a part in the breakdown or metabolism of foodstuffs (table 38-1).

A two-layer membrane, the peritoneum, ilnes the abdominal cavity and covers the surfaces
of the abdominal organs. Lubricating fluid between the two layers permits the organs to move
without friction during breathing and digestive movements.

MOUTH

Food is taken into the mouth, where the teeth, tongue, and salivary glands begin the process of food
digestion. As the teeth cut and grind the food, the salivary glands secrete saliva-a watery solution
that contains amylase (ptyalin). Amylase is an enzyme that initiates the breakdown of
carbohydrates. The tongue helps by mixing saliva with the food and pressing it against the teeth.
When the bolus is to be swallowed, the tongue forces the food into the pharynx.

PHARYNX

The pharynx is a muscular structure that is shared by the digestive and respiratory tracts. It joins the
mouth and nasal passages to the esophagus. During swallowing, the epiglottis covers the airway like
a trapdoor to prevent food from enterning the respiratory tract.

ESOPHAGUS

Food moves from the pharynx into the esophagus, a long muscular tube that passes through the
diaphragm into the stomach. Gravity helps but is not essensial for the movement of food through
the esophagus. Circular, wavelike contractions of the muscules of the digestive tract propel food
dwon the tract. This movement is called peristaltis.

STOMACH

The stomach is the widest section of the digestive tract. It is the separated from the esophagus by
the cardiac sphincter. The stomach is not very large ehen empty, but it expands considerably when
food is present. It consists of three section : (1) the fundus, (2) the body, (3) the pylorus. A unique
arrangement of muscle layers allows the stomach to churn the food, mixing it with gastric secretions
until it becomes a semiliquid mass celled chyme. Gastric secretions incule rennin, pepsin,
hydrochhloric acid, and lipase. Rennin starts to break down milk proteins, lipase breaks down fats,
and pepsin and hydcochloric acid partially digest proteins. The pyloric sphincter between the
stomach and the small intestine keeps food in the stomach until it is properly mixed.

SMALL INTESTINE

Chyme leaves the stomach and enters the small intestine, where chemical digestion and absorption
of nutrients take place. The small intestine is approximately 20 feet long and consists of three
sections: (1) the duodenum, (2) the jejenum, and (3) the ileum.

Liver and pancreatic secretions enter the digestive tract in the duodenum. Bile, produced in
the liver and stored in the gallbladder, break down large fat globules. Pancreatic enzymes further
reduce the fat to glycerol and fatty acids, wich can easily be absorbed. The fuctions of the liver,
gallbladder, and pancreas are discussed in more detail in the chapter 39.

Three layers of tissue make up the walls of the small intestine. The mocous membrane layer
secretes the digestive enzymnes sucrase, lactase, maltase, carboxypeptidase, aminopeptidase,
dipeptidase, nucleosidase, lipase, and enterokinase. Enzymnes and their substrates are listed in the
table 38-1. The inner layer is lined with thousands of microscopic projections called villi. Digested
food molecules are absorbed through the villi into the bloodstram. Muscle layers contract to
continue mixing the chyme, moving it toward the large intestine.

LARGE INTESTINE AND ANUS

Chyme enters the large intestine through the ileocecal valve. The first section of the large intestine is
the cecm, where the appendix is located. The large intestine goes up the right side of the abdomen
(the ascending colon), across the abdomen just below the wist (the trasverse colon), and down the
left side of the abdomen ( the descending colon ). The part of the descending coon beetwen the iliac
crest and the rectum is called the sigmoid colon. The last 6 to 8 incheas of the large intestine is the
rectum, wich ends at the anus, where wastes leave the body. The presence of sphincters in the anus
allow wastes to be stored until voluntary elimination occurs.

Unlike the small intestine has no villi and secretes no digestive enzymes. Its function is to
absorb water from thr chymr and eliminate the remaining dolid wastes in the from of faces.

AGE-RELATED CHANGES

Normal aging generally doest not significantly impair ingestion, digestion, absorption, or elimination.
When acute or chronic illnesses occur, however, the older person is at increased risk for problems
digestion and elimination

The teeth are mechanically worn down with age. They appear darker and somewhat
transparent. The givingva (gum) tends to recede. Although tooth loss is not a normal effect of aging,
about 40% of all Americans ages 65 years and older are edentilous. The main reasons for tooth loss
are caries and periodontal disease. Many older people have complate or parsial dentures. The jaw
may be affected by osteoarthritis. A significant loss of taste buds occurs with age. The older person
may be able to detect sweet better than other taste. Xerostomia (dry mouth) is common but may be
caused more by poor hydration and drug side effects than by aging.

The walls of the esophagus and stomach become thinner with aging, and secretions lessen.
The esphageal sphincters that normally prevent the reflux of gastric contents are more relaxed. The
production of hydrochloric acid and digestive enzymes decreases. Gastric motor activity slows; thus
gastric emptying is delayed and hunger contractions diminish. Ni signnificant changes withe age
occur in the small intestine. The absorption of vitamin A may increase, whereas the absorption of
vitamin D, calcium and zink may be reduced. In the large intestine, the muscle layer and mucosa
atrophy. Smooth muscle tone and blood flow decrease, and connective tissue increase. Movements
of contents through the colon are slower. The anal sphincter tone and strengh decrease.

Constipation is a frequent complaint among older adults, and they use laxative more often
than do young people. May experts belive that constipation is not a normal age-related change but
rather is caused by such factors as low fluid intake, lack of dietary fiber, inactivity, drugs, depression,
and hypothyroidism.

NURSING ASSESSMENT OF THE DIGESTIVE TRACT

HEALTH HISTORY

Cheif Complaint and History of Present Illness

Although the registred nurse (RN) should perform thr complete assessment, the licensed practical
nurse/licensed vocational nurse (LPN/LVN) contributes to the database. Therefore the complete
nursing assessment is detailed here. The health history begins with a detailed description of the
present illness. Complaints may include weight changes, problems with food ingestion, symptoms of
digestive disturbances, or changes in bowel elimination.

Past Medical History

The past medical history may disclose recent surgery, trauma, burns, or infections. Note serious
illnesses such as diabetes, hepatitis, anemia, peptic ulcers, gallbladder disease, and cancer. Identify
any alternative methods of feeding or fecal diversion (ileostomy, colostomy). If feedingd are given
nasogastric, grastrostomy, enterostomy, or esophagogastrostomy tubes, then record the type and
amountof feedings, as well as the feeding schedule. the past history also includes a list of recent and
current medications, both prescription and over-the-counter (OTC) drugs. Use of antacid and
laxative agents is especially important to note. Also record any food allergy or intolerance, with a
description of the rection that occurs when the offending food is eaten.

Family History

Inquire whether the patient has a family history of diabetes, cancer of the digestive tract, peptic
ulcers, gallbladder disease, hepatitis, alcoholism, intestinal polups, or obesity.

Riview of Systems

The riview of systems begons with a descroption of the patent’s general health state. Ask about
changes in the skin,includding dryness, bruising, and prunitus (itching), and determine whether the
patient has nay mouth problems, specifically lesions, bleeding increased or decreased salivation,
abnormal tastes or odors, and pain. Document if the patient has dentures, partial plates, or natural
teeth, and record the last dental examination. Note any problems with vhewing or swallowing and
inquire aboute changes in appetite, food intake and weigh. If nausea, vomiting, dyspepsial
(indigestion), heartburn, flatus, abdominal distention, or pain is present, then indentify factors that
seem to be related to the symptoms. Describe pain location, along with preci[itating factors,
relationship to meals, and measures that relive tha pain. Assessment of elimination includes usual
bowel habits and recent changes, flatulence (gas), changes in stool characteristics (frequency,
amount, color, consistency), bleeding, and painful defecation.

Functional Assessment

The functional assessment focuses on nutrion, activity, and stressors. Information about general
dietary habits should include the daily pattern of food intake (mealtimes, food eaten in a typical day,
food likes and dislakes, and use of food supplements), attitudes and beliefs about food, and changes
in dietary habits related to health problems. Discribe the effects of the cheif complaint to usual
functioning and note whether the patient is able to obtain and prepare food and eat independently
(see the nutrition concepts box).

PHYSICAL EXAMINATION

Begin the physical examination with the measurement of the patien’s height, weight, and vital signs.
Observe the patient’s general appearance, noting skin color, texture, and turgor; posture; motor
activity; and responses to intruction.

Head and Neck

Inspection of the mouth determines the condition of the lips, teeth, gums, tongue, and mucous
membranes. Describe caries, moisture, color, and lesions and note any unpleasant or unusual odors
of the mouth. If the patient has dentures, then examine the mouth with and without the dentures in
places. A tongue blade is needed to depress the tongue and examine the pharynx. Instruct the
patient to say’’ah’’ while observing yhe movement of the the uvulva and soft palate. Normally, the
uvula and palate move upward, with the uvula remaining in the midline.

Pharmacology Capsule

Many drugs affect gastrointestinal (GI) function, causing anorexia, nausea, vomiting, and diarrhea, or
constipation.

Nutrition Considerations

1. People with gastric ulcers experience increased pain after eating

2. People with duodenal ulcers experience decreased pain after eating
3. A peptic ulcer diet is individualized and usually consist of small to moderate-sized
melas, avoiding foods that cause an increase in gastritic acid secration or consistently
case distress
4. Diarrhea is caused by phatologic organisms, diet intestinal lesions, or irritations
associated with various diseases or condition
 5. The major nutrional goal of therapy for diarrhea is to replace lost fluids
6. Constipation is caused by insufficient fiber intake, insufficient fluid intake, lack of
exercise, some drugs, and the habitual use of laxative agents
7. The dietary treatment of constipation consists of increasing fluid (8 to 10 glasses of
water a day) and fiber intake
8. A hot drink such as coffee or tea enhances peristalsis and promotes defecation

Abdomen

For the abdominal examination , the patient should be supine, with the head raised slightly and the
knees slightly lfexed. The areas of the abdomen are commonly described as quadrants. An
imaginary line is drawn horizontaly across the abdomen at the level of the umbilicus. A second
imaginary line extends from the sternum to the pubic bone. This creates the four quadrants: (1) the
right upper quadrant, (2) the left upper quadran, (3) the right lower quadrant, and (4) the left lower
quadrant. Findingd can then be documented by anatomic location (figure 38-2)

Inspection. Inspect the skin of the abdomen for color, texture, scars, striae (“stretch marks”), rashes,
lesions, and dilated blood vessels. Describe the general countour of the abdomen as flat, convex
(rounded), concave (sunken), protuberant, or distended. Note the location and contour of the
umbilicus. Aortic pulsation and peristalsis are sometimes observed , especially in thin people.

Auscultation. After inspecting the abdomen, auscultate the abdomen to assess bowel sounds.
Auscultation is done before palpation because can alter normal bowel sounds. The diaphragm of the
stethoscope should be warmed and used to listen to each quadrant. Normal bowel sounds include
clicks and gurgels that occur five to thirty times per minute. Listen to each quadrant for at least 2
minutes. If no sounds are heard, then it is important to listen for a full 5 minutes before recording
bowel sounds as absent. Bowel sound may be described as present, absent, increased, decreased,
high-pitched, gurgling tinkling, or gushing. Loud gurgling sounds are called borborygmi. Record he
presence or absence of bowel sounds in each quadrant.

Percussion. Nurses with advenced training in physical examination use percussion and palpation ti
collect additional data. Percussin is tapping on the skin to detect the presence of air, fluid, or masses
in the margins of internal organs. Percussion oven an air-filled organ produces a high-pitched, hollow
sound called tympany. Tympany is similar to the sound made by a kettle drum. Percussion over a
solid or fluid-filled struvture sounds dull and flat. Normally, tympany is heard more often than
dullness. All four quadrants of the abdomen should be precussed.

Palpation. Palpation is done to detect tenderness, sensitivity, masses, swelling, and muscular
resistance. The examiner holds his or her fingers together and depress the abdomen gently in all
four qudrants. Light palpation depresses the abdominal wall only about 1 cm. Deep palpation uses
more pressure. To assess for rebound tenderness, the abdomen is depressed and then quickly
released. Deep palpation and tests for rebound tenderness should be done only by people who are
trained in these techniques.

RECTUM AND ANUS

Glovers are worn when examining the anus and perianal area. Inspect the perianal skin color, rashes,
and lesions, and note the presence of any external hemorrhoids. The rectal examination is
performed by a trained examiner. The LVN/LPN may help position, drape, and comfort the patient.
The examiner insert a gloved, lubricated finger into the rectum and points it down as if to have a
bowel movement. This relaxes the anal sphincter. The examinar palpates for lumps and tenderness
in the rectum.

Assessment of the patient with a degetive tract disorde is summarized in box 38-1.

DIAGNOSTIC TESTS AND PROCEDURES

Diagnostic tests for digestive disorders include radio graphic studie, endoscopic examinations, and
laboratorium studies. Always advise patients about te test and procedures and be sure required
consent forms are signed.

For radiographs and imaging procedures, follow agency protocol regarding nothing-by-
mouth (NPO) orders and other preparation. If contrast media will be used, assess for allergy to the
“dye”, iodine, and shellfish. If the patient is allergic to any of these, then the radiologist should be
notified.

For laboratory blood test, tell the patient a blood sample will be taken and whether NPO is
reqired. For a urine specimen, instruct the patient in the collection procedure. Studies are described
briefly in able 38-2.

BOX 38-1

ASSESSMENT OF THE PATIENT WITH A DISORDER OF THE DIGESTIVE TRACT

HEALTH HISTORY

Present illnes

Weight changes, problems with food ingestion, symptomd or digestive disturbances, alterations in
bowel elimination.

Past medical history

Recent surgey, trauma, infections; history of diabetes melitus, hepatitis, anemia, peptic ulcers,
galdbladder disease, cancer; alternative methods of feeding; type, amount, schedule; fecal diversion
: type; allergies: food, drugs

Family history

Diabetes melitus, cancer of the digestive tract, hepatitis, anemia, peptic ulcers, galdbladder disease,
alcoholism, intestinal polyps, obesity

Riview of systems

Skin color, pruritus

Oral cavity
Presence and condition of teeth, condition of gumd, modture, pain, abnormal tastes or ordors,
difficulty chewing

Appetite

Dysphagia

Digestive disturbances

Nausea, vomiting, dyspepsia, heartbum, pain

Bowel elimination

Changes, pain, flatulence, bleeding, stool characteristics

Functional assessment

Dietary pattern, attitudes and beliefs about food, activity, stressors

PHYSICAL EXAMINATION

Hight and weight

Vital signs

General appearance

Head and neck

Condition of teeth, gums, tongue, mucous membranes, ordors, uvula position

Abdomen

Skin color, texture, scars, striae, rashes, lesions, dilated, blood vessels; abdominal contour, distentio;
umbilicus location and contour; bowel sounds; abdominal tenderness, masses, swelling, muscular
resistance, rebound tenderness

Perianal skin

Color, rash, lesions; hemorrhoids

RADIOGRAPHIC STUDIES

Radiogrhaphic studies include the upper gastrointestinal (UGI or GI) series (barium swallow), small
bowel series, and barium enema examination. Radiographs of the gallbladder are obtained as well
and are discussed
TABLE 38-2 DIAGNOSTIC TESTS AND PROCEDURES

TEST/ PURPOSE

Radiographic test

 Upper gastrointestinal (UGI) or gastrointestinal (GI) series : Barium swallow detects

banormalities of esophagus and stomach.
 Small bowel series setect abdominalities of the small intestine
 Barium edema detects abnormalities of the large intestine

Endoscopic test

Upper digestive tract

 Esophagoscopy visualizes the esophagus

 Gastroscopy visualizes the stomach
 Gastroduodenoscopy visualizes the stomach and duodenum
 Esophagosastroduodenoscopy visualizes the esophagus, stomach, and duodenum
 Endoscopic retrograde cholangiography visualizes the bile ducts and galdbladder

Lower digestive tract

 Colonoscopy visualizes the colon

 Proctoscopy visualizes the rectum
 Sigmoidoscopy visualizes the rectum and sigmoid colon

PATIENT PREPARATION

Radiographic test

 Inform the patient that he or she will need to drink a solution containing contrast medium.
Radiographs will be taken of the esophagus, stomach, and duodenum via fluoroscope. Films
will be repated 6 hours later to see how much barium has passed through the stomach. The
patient should taken nothing by mouth (NPO) 6-8 hours before the procedure, per agency
protocol
 The patient drinks a contrast solution. Films are taken at 20-to 30 minute intervals as the
solution passes through the small intestine. The patient will be asked to assume various
position for the radiographs. The procedure may take several hous. Preparation is the same
as for thr UGI series.
 A contrast solution is administered by enema, and radiographs are taken with the patient in
the patient in a variety of positions. The test may take as long as 11/4 hours to complete. The
patient may be restricted to only clear liquids the day or evening before the procedure. A
laxative and enemas sre given on the previous day. Usually the patient is NPO after
midnight. Enemas are given until the intestine is clear on the morning of the procedure.
Endoscopic test

Upper digestive tract

 Upper digestive tract examination include the following patient preparations; NPO for 6-8
hours. If ordered, then give the patient a sedative shortly before the examination

Lower digestive tract

 Lower disetive tract examination include the following patient preparations : NPO for 6-8
hours before the examination. The patient may be restricted to only liquids the previous day
or evening. Bowel cleansing may be done with cathartic agents, suppositories, and enemas
 Cathartic agents and suppositories are usually given the evening before the test. Enemas
may be ordered on the morning of the test until the colon is clear

POSTPROCEDURE NURING CARE

Radiographic test

 Monitor stools for at least 2 days for passage of white stools that show that barium is being
eliminated (normal stool color returns in 3 days). Laxative agents may be ordered to
promote elimination. Provide food, extra fluids, and rest
 Care is the same as for the UGI series
 Care is the same as for the UGI series

Endoscopic test

Upper digestive tract

 The patient should be NPO until the gag reflex returns. Monitor the patient for signs of
trauma: bleeding from the throat or rectum. Monitor the patient for signs of : fever,
abdominal digestion, cramping pain, and vague discomfort

Lower digestive tract

 Monitor the patient for signs of : fever, abdominal digestion, cramping pain. Assess for rectal
bleeding

TABLE 38-1 DIGESTIVE ENZYMES AND SUBSTRATES

SITE

 Mouth
 Stomach
  Small intestine

ENZYME

Mouth

 Ptyalin

Stomach

 Rennin
 Pepsin
 Lipase

Small intestine

Pancreatic enzymes :
 Trypsin
 Chymotrypsin
 Carboxypolypeptidase
 Ribonuclease
 Deoxyribonuclease
 Elastase
 Lipase
 Cholinesterase ester
 α- amylase

small intestine :

 carboxypeptidase
 aminopeptidase
 dipeptidase
 nucleosidase
 enterokinase
 lipase
 sucrase
 α – Dextrinase
 maltase
 lactase

Quadrants Of The Abdomen And Their Underlying Organs*

Right upper quadrant (RUQ)

 Adrenal gland (right)

 Colon ( hepatic fluxure and portions of ascending and transverse)
  Duodenum
 Kidney (right bole)
 Gallbladder
 Pancreas (head)
 Pylorus

Right lower qudrant (RLQ)

 Appendix
 Bladder (if distended)
 Cecum
 Colon (portion of ascending)
 Kidney (lower polw of right)
 Ovary (right)
 Salpinx (uterine tube; right)
 Spermatic cord ( right )
 Urete ( right)
 Uterus (right)

Left upper quadrant (LUQ)

 Adrenal gland (right)

 Colon (splenic flexure and portions of trasverse and descending)
 Kidney (portion of left)
 Liver (left tube)
 Pancrease (body)
 Spleen
 Stomach

Ledt lower quadrant (LLQ)

 Bladder (if distended)

 Colon (sigmoid and portion of descending)
 Kidney (lower pole of left)
 Ovary (left)
 Salpinx (uterine tube; left)
 Spermatic cord (left)
 Uteter (left)
 Uretus (if enlarged)