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Gerontological Nursing, Second EditionPatricia A. Tabloski
LEARNING OUTCOME 1Describe age-related changes that affect
gastrointestinal function.
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Gerontological Nursing, Second EditionPatricia A. Tabloski
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
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Gerontological Nursing, Second EditionPatricia A. Tabloski
FIGURE 20-1NORMAL CONFIGURATION OF THE GI TRACT.
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Gerontological Nursing, Second EditionPatricia A. Tabloski
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
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Gerontological Nursing, Second EditionPatricia A. Tabloski
LEARNING OUTCOME 2Describe the impact of age-related changes of
gastrointestinal function.
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Gerontological Nursing, Second EditionPatricia A. Tabloski
AGING AND THE GASTROINTESTINAL SYSTEM Aging has limited impact on system Aging associated with increased prevalence
of many GI disorders Evaluate disorders closely
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Gerontological Nursing, Second EditionPatricia A. Tabloski
FIGURE 20-2NORMAL CHANGES OF AGING RELATED TO THE GASTROINTESTINAL TRACT.
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DYSPHAGIA Number-one esophageal disorder in older
people Impacts oral intake Seen in 50% of institutionalized persons
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Gerontological Nursing, Second EditionPatricia A. Tabloski
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
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Gerontological Nursing, Second EditionPatricia A. Tabloski
DYSPHAGIA Signs and symptoms
Reports of difficulty swallowing Difficulty controlling food or saliva in mouth Facial droop Dementia, frailty, confusion Inability to sit upright
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Gerontological Nursing, Second EditionPatricia A. Tabloski
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
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DYSPHAGIA Risk factors
Incorrect positioning Inappropriate intake Rapid feeding Older persons labeled as “difficult”
Comorbidities Neurological disorders Muscular disorders Anatomical abnormalities
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Gerontological Nursing, Second EditionPatricia A. Tabloski
DYSPHAGIA Nursing assessment
Observation of individual during eating and drinking
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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
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Gerontological Nursing, Second EditionPatricia A. Tabloski
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
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Gerontological Nursing, Second EditionPatricia A. Tabloski
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
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Gerontological Nursing, Second EditionPatricia A. Tabloski
GASTROESOPHAGEAL REFLUX DISEASE Risk factors
Aging Thyroid disease Scleroderma or connective tissue disorders Diabetes
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Gerontological Nursing, Second EditionPatricia A. Tabloski
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
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Gerontological Nursing, Second EditionPatricia A. Tabloski
GASTROESOPHAGEAL REFLUX DISEASE Triggers
Eating large meals Certain medications High-fat foods High caffeine intake Alcohol and tobacco use Reclining after eating Obesity
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Gerontological Nursing, Second EditionPatricia A. Tabloski
GASTROESOPHAGEAL REFLUX DISEASE Consequences for GERD Nursing assessment of GERD Diagnostic testing
Barium swallow Endoscopy Esophageal contents pH
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GASTROESOPHAGEAL REFLUX DISEASE Goals of treatment
Symptom control Heal mucosal injury
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Gerontological Nursing, Second EditionPatricia A. Tabloski
GASTROESOPHAGEAL REFLUX DISEASE Lifestyle modifications
Elevate head of bed Reduce portion size Avoid trigger foods Drink 6 to 8 ounces of water with medications
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Gerontological Nursing, Second EditionPatricia A. Tabloski
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
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GASTROESOPHAGEAL REFLUX DISEASE Medications
Antacids Aluminum-containing antacids Histamine 2 receptor agonists Proton pump inhibitors Combination drugs
Surgery
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Gerontological Nursing, Second EditionPatricia A. Tabloski
GASTRIC DISORDERS Gastritis
Inflammation of the gastric mucosa Classification
Severity Site involvement Inflammatory cell type
Diagnosis Endoscopy
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Gerontological Nursing, Second EditionPatricia A. Tabloski
GASTRIC DISORDERS Gastritis
Treatment Reducing contributing factors Acid neutralization and suppression Protection of gastric mucosa Antibiotic therapy Transfusions as needed
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Gerontological Nursing, Second EditionPatricia A. Tabloski
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
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GASTRIC DISORDERS Peptic and duodenal ulcer disease
Treatment Discontinue use of NSAIDs, alcohol, tobacco, and
caffeine Small, frequent meals Medications
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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
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Gerontological Nursing, Second EditionPatricia A. Tabloski
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
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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
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LOWER GASTROINTESTINAL TRACT DISORDERS Diverticular disease
Risk factors Physical inactivity Constipation Obesity Smoking NSAID therapy
Management Increase fiber intake
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Gerontological Nursing, Second EditionPatricia A. Tabloski
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
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LOWER GASTROINTESTINAL TRACT DISORDERS Assessment of diverticular disease
Physical examination Questions regarding bowel history
Diagnosis Abdominal CT scan Ultrasound
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LOWER GASTROINTESTINAL TRACT DISORDERS Goals of treatment
Eliminate bacterial infection Liquid diet advancing to low fiber to allow colon
to rest
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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
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INFLAMMATORY BOWEL DISEASE Ulcerative colitis
Diagnosis Sigmoidoscopy Colonoscopy Rectal mucosa biopsy Stool specimens
Treatment Oral corticosteroids 5-ASA drugs Surgery
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INFLAMMATORY BOWEL DISEASE Crohn’s 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
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Gerontological Nursing, Second EditionPatricia A. Tabloski
INFLAMMATORY BOWEL DISEASE Crohn’s disease
Diagnosis Abdominal CT scan Complete blood cell count Barium enema colonoscopy
Treatment Oral corticosteroids Surgery
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Gerontological Nursing, Second EditionPatricia A. Tabloski
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
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Gerontological Nursing, Second EditionPatricia A. Tabloski
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
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BENIGN AND MALIGNANT TUMORS Malignant tumor
Signs and symptoms Change in bowel habits Abdominal pain Abdominal mass Anemia Rectal bleeding Weight loss
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Gerontological Nursing, Second EditionPatricia A. Tabloski
BENIGN AND MALIGNANT TUMORS Malignant tumor
Diagnostic testing Colonoscopy Carcinoembryonic antigen levels Sigmoidoscopy Fecal occult blood testing
Treatment Surgical resection
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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
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Gerontological Nursing, Second EditionPatricia A. Tabloski
ANTIBIOTIC THERAPY ASSOCIATED DIARRHEA AND COLITIS Signs and symptoms
Watery, nonbloody diarrhea Low abdominal pain Fever
Potential complications Dehydration Hypotension Colonic perforation
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ANTIBIOTIC THERAPY ASSOCIATED DIARRHEA AND COLITIS Diagnosis
Stool perforation Treatment
Metronidazole Vancomycin
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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
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Gerontological Nursing, Second EditionPatricia A. Tabloski
CONSTIPATION Predisposing factors
Aging Certain medications Metabolic and endocrine disorders Muscular dystrophy Neurologic disorders Recent abdominal surgery Obstructive disorders
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Gerontological Nursing, Second EditionPatricia A. Tabloski
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
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Gerontological Nursing, Second EditionPatricia A. Tabloski
CONSTIPATION Assessment
Evaluate complaint Management
Education Hydration Increased mobility Fiber supplementation
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Gerontological Nursing, Second EditionPatricia A. Tabloski
CONSTIPATION Assessment
Management Medication
Bulk laxative Stool softeners Osmotic laxatives Magnesium containing laxatives Senna Suppositories and enema
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Gerontological Nursing, Second EditionPatricia A. Tabloski
DIARRHEA Defined as abnormally loose stool
accompanied by change in frequency or volume
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Gerontological Nursing, Second EditionPatricia A. Tabloski
DIARRHEA Causes
Virus Food poisoning Food contamination Medications Lactose intolerance
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Gerontological Nursing, Second EditionPatricia A. Tabloski
DIARRHEA Symptoms
Urgency Cramping Bloating Incontinence Pain on defecation Presence of blood in stool
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Gerontological Nursing, Second EditionPatricia A. Tabloski
DIARRHEA Assessment
Interview Physical examination
Management Antidiarrheal agents Soluble fiber
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Gerontological Nursing, Second EditionPatricia A. Tabloski
FECAL INCONTINENCE Seen in 50% of institutionalized elderly Cause
Mobility problems Severe depression Cognitive impairment
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Gerontological Nursing, Second EditionPatricia A. Tabloski
HEMORRHOIDS AND RECTAL BLEEDING Hemorrhoids and colorectal cancer most
common causes of rectal bleeding Hemorrhoids are varicose of anorectal
junction Treatment based upon size
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LIVER AND BILIARY DISORDERS Signs and symptoms
Older adults often present with vague, ambiguous symptoms
Fatigue Weight loss Anorexia Malaise
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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
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LIVER AND BILIARY DISORDERS Hepatic cysts
Common in older adults Typically benign
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LIVER AND BILIARY DISORDERS Metastatic carcinoma
Most common liver cancer Highest rates in those aged 50–70 Associated with alcohol and tobacco use
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LIVER AND BILIARY DISORDERS Metastatic carcinoma
Signs and symptoms Jaundice Variceal bleeding Ascites Right upper quadrant pain Weight loss Enlarged liver
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LIVER AND BILIARY DISORDERS Metastatic carcinoma
Diagnostic tests Liver function tests Abdominal ultrasound CT scan Liver biopsy
Treatment based upon tumor stage and patient’s health status
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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
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LIVER AND BILIARY DISORDERS Gallstones
Diagnostic testing Abdominal CT scan Ultrasound
Treatment Laparoscopic cholecystectomy Pharmacological dissolution Extracorporeal shock wave lithotripsy Dietary modifications
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LIVER AND BILIARY DISORDERS Pancreatitis
Acute pancreatitis Symptoms
Epigastric pain Nausea and vomiting Elevated serum liver function studies
Amylase Lipase Bilirubin Alkaline phosphatase
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LIVER AND BILIARY DISORDERS Pancreatitis
Acute pancreatitis Treatment
Nasogastric suction Pain management Hyperalimentation Fluid replacement
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LIVER AND BILIARY DISORDERS Pancreatitis
Chronic pancreatitis Symptoms
Weight loss Diarrhea Diabetes Persistent pain
Treatment Behavior modification Surgery
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LEARNING OUTCOME 3Identify risk factors to health for the older person
with gastrointestinal problems.
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MEDICATIONS WITH POTENTIAL TO AFFECT THE GASTROINTESTINAL TRACT Anticholinergics
Antidepressants Neuroleptics Antihistamines Antiparkinsonian agents
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MEDICATIONS WITH POTENTIAL TO AFFECT THE GASTROINTESTINAL TRACT Antihypertensives
Calcium channel blockers ACE inhibitors Diuretics
Iron and calcium supplements Aluminum-containing antacids Opiates Laxatives
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MEDICATIONS AS RISK FACTORS FOR ESOPHAGEAL INJURY Nonsteroidal anti-inflammatory drugs
(NSAIDs) Potassium chloride Tetracycline Quinidine Alendronate Ferrous sulfate Theophylline
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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”
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GERD RISK FACTORS Primary
Length and frequency of esophageal acid exposure
Others Thyroid disease Diabetes Scleroderma Connective tissue disorders
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RISK FACTORS FOR LARGER ULCERS Higher doses of NSAIDs History of peptic ulcer disease Concurrent use of anticoagulants
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LIFESTYLE FACTORS CONTRIBUTE TO RISK OF DIVERTICULOSIS Inadequate dietary fiber intake
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PREDISPOSING FACTORS FOR BENIGN TUMORS Age Diet Family history Prior diagnosis of polyps
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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
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DRUGS COMMONLY ASSOCIATED WITH DIARRHEA Nonsteroidal anti-inflammatory drugs
(NSAIDs) Magnesium-containing antacids Antiarrhythmics Beta-blockers Quindine Colchicines Digoxin
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RISK FACTORS FOR CONSTIPATION Dehydration Side effects of medications
Anticholinergic side effects Antidepressants Neuroleptics Antihistamines Antiparkinsonian agents
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RISK FACTORS FOR CONSTIPATION Side effects of medications
Selected antihypertensive agents Calcium channel blockers ACE inhibitors Diuretics
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RISK FACTORS FOR CONSTIPATION Side effects of medications
Iron supplements Calcium supplements Aluminum-containing antacids Benzodiazepines Antiarrhythmics Opiates
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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
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RISK FACTORS FOR FECAL INCONTINENCE Dementia Depression Chronic pain Lack of mobility Lack of sensation
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FACTORS THAT INCREASE RISK FOR PANCREATITIS Gallstones Hyperlipidemia Hypercalcemia
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FACTORS THAT INCREASE RISK FOR PANCREATITIS Medications
Estrogen Furosemide ACE inhibitors Mesalamine
Alcohol abuse Cancer
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LEARNING OUTCOME 4Describe unique presentations of gastrointestinal
problems in the older person.
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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 age-related change
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OTHER DISORDERS RESULTING IN GI SYSTEM CHANGES Diabetes Neurological illness Vascular disorders
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LEARNING OUTCOME 5Define appropriate nursing interventions directed
toward assisting the older adult with gastrointestinal problems to develop self-care
abilities.
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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
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LIFESTYLE MODIFICATION FOR GERD Lose weight as appropriate Avoid tight clothing Remain in upright position after eating Reduce alcohol, caffeine, and fat intake
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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
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LIFESTYLE MODIFICATION FOR PEPTIC/DUODENAL ULCER DISEASE Discontinue use of all NSAIDs Discontinue use of alcohol, tobacco, and
caffeine Avoid offending foods
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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
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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
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NURSING MANAGEMENT OF CONSTIPATION Patient education
Dietary intake of fluid and fiber Exercise Awareness in bowel habits Understanding of potential impact of selected
medications
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LEARNING OUTCOME 6Identify and implement appropriate nursing
interventions to care for the older person with gastrointestinal problems.
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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
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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
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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
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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)
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RELATED FACTORS IDENTIFIED BY NANDA IN 2003 Neuromuscular impairment Decreased strength or excursion of muscles
involved in mastication Perceptual impairment
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RELATED FACTORS IDENTIFIED BY NANDA IN 2003 Mechanical obstruction (edema,
tracheostomy tube, tumor) Fatigue Limited awareness Reddened, irritated oropharyngeal cavity
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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
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NURSING INTERVENTIONS FOR FECAL INCONTINENCE Regular toileting program Administration of high-fiber diet Elimination of medications associated with
diarrhea Treatment of infections
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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
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ENDOSCOPIC GASTROINTESTINAL PROCEDURES Colonoscopy
1 to 2 days of liquid diet Cathartic evening prior Monitor patients with cardiovascular or renal
instability
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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
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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)
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