METABOLISM

THE DIGESTIVE SYSTEM

SALIVARY G.
MOUTH
Stimulated by presence of food in the mouth Chewing = 5th CN Submandibular Sublingual Parotid Produces: PTYALIN

STOMACH
Churns to form CHYME Mucosal Barrier Rugae : Parietal Cells HCl + IF Epithelial Cells HCO3 Chief Cells Pepsin Goblet Cells - Mucus

ESOPHAGUS
Peristalsis

SMALL INTESTINES
Parts Payers Patches Plica Circularis Villi Absorption Duodenum Fe & Ca Jejunum Na, Cl, CHO, CHON, FATS Ileum VB12, Bile salts all throughout Mg, P, K

LARGE INTESTINES
Parts Reabsorption Elimination Goblet cells mucus No Villi Fermentation of gas Putrefaction liberates NH4, indol, skatol to stools Bacteria: E. Coli Feces

APPENDIX
Lymphatic Functions

GASTROINTESTINAL TRACT EPITHELIAL LAYERS

THE DIGESTIVE SYSTEM

THE LIVER, PANCREAS, & GALLBLADDER

PANCREATIC ACINI (EXOCRINE)

DUCT CELLS OF ISLANDS OF LANGERHANS (ENDOCRINE) ALPHA CELLS

BETA CELLS

THE DIGESTIVE SYSTEM ACCESSORY ORGANS

GALL BLADDER
Storage of bile 30-50ml (70ml max) Bile = emulsify fat Bile salts, acids, cholesterol, bilirubin, phospholipids

LIVER
R & L HEPATIC DUCT

CYSTIC DUCT SPHINCTER OF ODDI

GALL BLADDER PANCREAS

LIVER
Largest Gland - RUQ Functions: Regulate Blood glucose Secrete Bile Store filter detoxify blood Synthesize Vit K Synthesize Plasma proteins Kupffer cells phagocytic axn Stores vitamins & minerals Converts NH4 & bacteria to urea

PANCREATIC DUCT COMMON HEPATIC DUCT AMPULLA OF VATER

PANCREAS
Exocrine: juices pH ^ 1200-3000ml Endocrine BIGADS

G.I.T. FUNCTION
RESPONSIBLE FOR PROCESSING FOOD, BREAKING IT DOWN INTO USABLE PROTEINS, CARBOHYDRATES, MINERALS, FATS, AND OTHER SUBSTANCES, AND INTRODUCING THESE INTO THE BLOODSTREAM SO THAT THEY CAN BE USED BY THE BODY.

PROCESSES
1. INGESTION 2. DIGESTION - Mechanical - Chemical - Secretion of Digestive enzymes 3. ABSORPTION 4. ELIMINATION

DIGESTIVE ENZYMES
ENZYMES THAT DIGEST SOURCE PRODUCTS

CARBOHYDRATES
Amylase Sucrase, Maltase, isomaltase, lactase Pancreatic amylase Salivary glands Intestinal fluids Pancreas Starch Maltose disaccharides monosaccharides starch maltose & isomaltose

FATS
Gastric Lipase Intestinal Lipase Bile Gastric Mucosa Intestinal fluids Gall Bladder Digests butterfat fats glycerol & fatty acids

PROTEIN
Pepsin Hydrochloric acid Peptidases Trypsin Chymotrypsin Carboxypeptidase Gastric Mucosa Gastric Mucosa Intestinal glands Pancreas Pancreas Pancreas proteoses, peptones & polypeptides protein polypeptds polypeptds amino a. peptides & amino acid proteins polypeptide pp smaller peptides

OTHERS
Enterokinase Nucleases Duodenal Mucosa Pancreas Activates trypsin Splits nucleic acids

REGULATORY SUBSTANCES
SUBSTANCE FUNCTION

HORMONAL REGULATORS
Gastrin Stimulates gastric glands to increase secretion of HCl. Triggered by stomach distention Stimulates gall to release bile into duodenum after detection of fat in duodenum Stops gastric secretion in the stomach ( inhibitory ) when pH of chyme in duodenum is less than 4-5

Cholecystokinin

Secretin

NEUROREGULATORS
Acetylcholine Sight, smell, chewing and stomach distention, stimulate gastric glands to increase production of acids. Inhibitory stimulus decreasing sphincter tone especially due to stress

Norepinephrine

LOCAL REGULATORS
Histamine Increases gastric acid production. Stimulates gastric glands

METABOLISM

AN ORGANIC PROCESS THAT CONTRIBUTE TO THE CHEMICAL CHANGES WITHIN THE CELL TO OBTAIN ENERGY.

2 PART PROCESS

ANABOLISM CATABOLISM

GLUCOSE METABOLISM
CARBOHYDRATES (Polysaccharides)
SALIVARY AMYLASE DISACCHARIDES (Sucrose, Maltose, Lactose) MONOSACCHARIDES (Glucose+Fructose) (Glucose+Galactose)

SUCRASE, MALTASE, LACTASE

END PRODUCT: GLUCOSE OXIDATION = ATP+H2O+CO2

Raises Blood Sugar

HIGH Blood Sugar

Glucagon

ALPHA cells
Glucose BETA cells

Glycogen

Insulin
Stimulates glucose uptake from blood

Tissue Cells (Muscles, kidney, fat)

Lowers Blood Sugar

LOW Blood Sugar

PROTEIN METABOLISM
PROTEINS
PEPSIN (Stomach) TRYPSIN (Pancreas) PEPTIDASES (Small Intestines) AMINO ACIDS

PEPTIDES

FAT METABOLISM
FATS (Triglyceride)

BILE
EMULSIFIED FATS LIPASE MONOGLYCERIDES GLYCEROL & Free Fatty Acids

ASSESSMENT
Chief Complaints
Abdominal pain Nausea & Vomiting Abdominal distention Dyspepsia Diarrhea Constipation & Hemorrhoids Anorexia & Weight loss Ascites Hematemesis Hematochezia / Melena Choking Dysphagia Jaundice Flatulence, Heartburn & Eructation

ASCITES

JAUNDICE

CHOKING

ASSESSMENT
Health History
Heredofamilial diseases Cultural & Religious beliefs History of surgery or trauma Changes in energy level Elimination & Urinary pattern Allergies Lifestyle activity, habits, coping Habits smoking, caffeine, alcohol Past Medical history Normal dietary pattern Collect dietary data Anthropometric Measurements weight, height, skin folds, IBW, BMI arm muscle circumference

Inspection
General appearance & posture Oral Skin characteristics Abdominal structure Abdominal contour

4 QUADRANTS

Auscultation
Listen to bowel sounds Record location, frequency and characteristics L : RUQ, LUQ, RLQ, LLQ F : N 8-20 per minute C : hypoactive ( 1-2 sounds in 2 mins ) hyperactive ( 5-6 sounds in less than 30 secs) absent ( no sounds within 5 minutes ) 1. hyperperistalsis 2. paralytic ileus 3. borboygmi

9 REGIONS

Right Hypochondriac

Epigastric

Left Hypochondriac

Right Lateral

Umbilical

Left Lateral

Right Inguinal

Hypogastric

Left Inguinal

Percussion
Stomach tympany Liver size dull to percussion Large intestines

Palpation
Pain, tenderness, organ size and position Masses especially liver enlargement; fluid wave test

DIAGNOSTIC EXAMS
1. Hematologic studies: CBC Electrolytes Serum Protein: A-G ratio Albumin:Globulin = 1.5-2.5:1 BUN Blood Urea Nitrogen = 7-20mg/100ml Serum Creatinine 2. Liver function test: Alkaline phosphatase 44-147 IU/L Prothrombin time 10 13 seconds Serum transaminase studies AST (aspartate aminotransferase ) formerly (SGOT): Serum glutamic oxaloacetic transaminase ALT (Alanine aminotransferase) formerly (SGPT): Serum glutamic pyruvic transaminase LDH (Lactodehydrogenase enzyme) Cholesterol Bilirubin

DIAGNOSTIC EXAMS
3. Analysis of Gastrointestinal Secretions Stool analysis Guaiac test, fecal fat analysis, culture. No red meat, NSAIDs, Vit C for 3 days To assess for bacteria, ova & parasites, malabsorption and blood Gastric secretion analysiscontents of stomach Assess ulcers. NPO for 8-10 hours, no anticholinergic meds, no smoking 4. Pancreatic functions Glucose levels RBS, FBS, OGTT N Glucose level : 80-120 mg/dl 5. Urine exam urea, glucose, acetone 6. Radiologic exams Flat plate of the abdomen abdominal x-ray No preparation needed Ultrasound of the gallbladder and liver Strict NPO after midnight prior to procedure Able to visualize if stones are present

LIVER ULTRASOUND

DIAGNOSTIC EXAMS
7. Radiographic studies a. Upper GI series (barium swallow) b. Lower GI series (barium enema) : NPO 6-8 hours before procedure : Lower GI liquid diet before procedure : Laxatives before and after procedure : Feces will be white. Normal within 72 hrs 8. Endoscopy a. Esophagogastroduodenoscopy b. Sigmoidoscopy / colonoscopy : NPO 6-8 hours before the procedure : Colon preps enema : upper visualization, check activation of gag reflex

9. Gallbladder evaluation a. Cholecystogram b. Cholangiogram : Introduction of dye check allergy : NPO post midnight : 12 telepaque tablets taken before test

Ventrodorsal View: Abdomen 3.5 hours after barium swallow

A. Ileum

B. Ascending Colon
C. Transverse Colon D. Descending
Colon

E. Site of Ileocolic &

Cecocolic Orifices

F. Cecum G. Gas in Stomach

LOWER G.I. SERIES BARIUM ENEMA

CHOLECYSTOGRAM

CHOLECYSTOGRAM

GALL BLADDER

DIAGNOSTIC EXAMS
10. Liver biopsy : Removal of liver tissue : Secure consent for procedure : No aspirin, NSAIDs, anticoagulants 2 weeks prior to scheduled procedure : NPO after midnight : Position on left side during biopsy : Position on right side after biopsy for 2 hours : Bed rest, observe for complications 11. Paracentesis : Removal of fluid accumulated in the peritoneum ( Diagnostic / Therapeutic ) : Void immediately prior to procedure : During procedure: sitting up with feet resting on stool : Fluid should be removed slowly over 30-90 minutes, generally below 1500cc

LIVER BIOPSY

PARACENTESIS

THE ENDOCRINE SYSTEM

THE HORMONES
GLAND OF ORIGIN

HORMONES Thyroid Stimulating H Follicle Stimulating H Luteinizing Hormone Interstitial Cell Stim H Growth Hormone Prolactin Adrenocorticotropic H Melanocyte Stim H Oxytocin Antidiuretic Hormone L-thyronine

ABBREV

ANTERIOR PITUITARY

TSH FSH LH ICSH GH ACTH MSH ADH T4 T3

POSTERIOR PITUITARY
THYROID GLAND

Triiodothyronine
Calcitonin

PARATHYROID

Parathyroid Hormone Glucocorticoids Minieralocorticoids Aldosterone

PTH

ADRENAL CORTEX

THE HORMONES
GLAND OF ORIGIN

HORMONES

ABBREV

ADRENAL MEDULLA OVARY TESTES PANCREAS BETA CELLS

Epinephrine
Norepinephrine Estrogen Progesterone Testosterone Insulin

PANCREAS Glucagon ALPHA CELLS

NURSING DIAGNOSIS & OBJECTIVES

DIAGNOSIS
Altered Nutrition ( less / more / potential ) Altered Elimination ( diarrhea / constipation ) Altered Comfort Activity intolerance Fluid loss / excess Impaired skin integrity Self care deficit, feeding Self esteem disturbance

GOALS
Maintain or Restore optimal nutritional status Promote healthy nutritional practices Decrease / regain specific weight Establish & maintain normal elimination pattern Promote comfort / alleviate pain Perform activities of daily living F & E will be restored or maintained Maintain or restore tissue integrity Client will feed self or receive help in feeding Develop or demonstrate positive self image

NUTRITION
THE SUM OF ALL THE INTERACTION BETWEEN AN ORGANISM AND THE FOOD IT CONSUMES
3 MAJOR FUNCTIONS OF NUTRIENTS
providing energy for body processes & movements providing structural material for body tissues & regulating body processes

3 PRINCIPLES OF NUTRITION I. ENERGY BALANCE - BMR, Body Weight Standards & Caloric Requirements II. ENERGY NUTRIENTS - Carbohydrates, Proteins & Fats

III. REGULATING NUTRIENTS - Vitamins, Minerals & Water

ENERGY NUTRIENTS
CARBOHYDRATES
Simple (sugar) - Monosaccharides: glucose, fructose, galactose - Disaccharides: combination, lactose Complex (starch & fibers) - Polysaccharide

PROTEINS
Essential amino acids (9) Non essential amino acids

FATS
Lipids Saturated, Unsaturated, Polysaturated, Mono Cholesterol

REGULATORY NUTRIENTS

VITAMINS
Water soluble Vitamins
C (Ascorbic acid) B1 (Thiamine) B2 (Riboflavin) B3 (niacin/nicotinic acid) B6 (Pyridoxine) B9 (Folacin/Folic Acid) B12 (Cobalamine) Panthothenic Acid

Prolonged Deficiency
Scurvy Beriberi Skin Lesions Pellagra Peripheral neutrils Megaloblastic anemia Pernicious anemia Fatigue ,sleep disturbance, Nausea, poor coordination Fatigue, depepression, muscle pain,dermatitis

Biotin

Fat Soluble Vitamins

A (Retinol) D (Ergocalciferol) E (Tocopherol) K (Menadione)

Prolonged Deficiency
Night Blindness Opacity of the lens Rickets Osteomalacia Anemia Bleeding

FOOD PYRAMID GUIDE

FACTORS AFFECTING NUTRITION

1. Development 2. Gender 3. Ethnicity and Culture 4. Beliefs about food 5. Personal preferences 6. Religious practices 7. Lifestyle 8. Medications and Therapy 9. Health 10. Alcohol Consumption 11. Advertising 12. Psychological Factors

ELIMINATION & DEFECATION

Waste products of metabolism should be eliminated from the body as feces or stool. Defecation expulsion of feces, bowel movement Factors that affect defecation 1. 2. 3. 4. 5. 6. 7. 8. 9. Developmental Diet Fluid intake Activity & exercise Psychological factors Medication Diagnostic procedures Anesthesia Pathologic condition

MEASURES TO STIMULATE APPETITE TO EAT

1. Serve food in pleasant and attractive manner 2. Place patient in comfortable position 3. Provide good hygiene measures 4. Promote comfort relieve pain, humidity, ventilation, 5. Remember that color affects appetite to eat 6. Assist weak patient in feeding

INTERVENTIONS FOR NAUSEA & VOMITING

1. Position: Conscioussemi-Fowlers Unconsious later 2. Prevent aspiration 3. Provide good oral care and hygiene 4. Suction the mouth as needed 5. Relieve sensation of nausea by providing any of the following: - Ice chips - Hot tea with lemon / calamansi - Hot ginger ale - Dry toast or crackers - Cold cola beverage

THE HEIMLICH MANEUVER

KINDS OF DIET
1. NPO 2. Clear diet / Liquid diet 3. Soft Diet 4. DAT 5. No Dark colored foods 6. Low fat, low cholesterol 7. High protein, low protein 8. Purine restricted 9. Gluten-free 10. Alkaline ash 11. Acid ash 12. Diabetic Diet 13. Kosher diet 14. Giovanni-giovanetti diet 15. Sattvic, Rajastic, Tamasic Vegetarian diet