3H ateneo de davao nursing metabolism lecture

2. METABOLISM

3. Anatomy and Physiology

4. MOUTH

5. The mouth, buccal cavity, or oral cavity is the first portion of the alimentary canal that receives food and begins digestion by mechanically breaking up the solid food particles into smaller pieces and mixing them with saliva. Lined with epithelial cells and mucuous membrane Lip muscle: orbicularisoris

6. TEETH

7. Enamel is the hardest and most highly mineralized substance of the body, the outer layer of tooth Dentin is the substance between enamel or cementum and the pulp chamber that acts as a protective layer and supports the crown of the tooth Cementum is a specialized bony substance covering the root of a tooth. Its principal role of cementum is to serve as a medium by which the periodontal ligaments can attach to the tooth for stability The dental pulp is the central part of the tooth filled with soft connective tissue. This tissue contains blood vessels and nerves that enter the tooth from a hole at the apex of the root

9. Digestion is the mechanical and chemical breaking down of food into smaller components, to a form that can be absorbed

10. Chewing Or mastication, is the mechanical process of breaking down food into smaller particles

11. Saliva Is secreted by the sublingual and submandibular and parotid glands Function: is to lubricate and soften food mass Contains the enzyme ptyalin (amylase) which breaks down starches to maltose Chewed food is then called bolus

12. Swallowing Or deglutition, is the act of passing down food/ bolus from the mouth down to the esophagus

13. Esophagus A hollow, muscular tube the lies posterior to the trachea and larynx Serves as the passage of food from the mouth to the stomach The Lower esophageal sphincter , a zone of increased pressure that provides a physiologic barrier to protect the esophageal mucosa from the effects of gastric reflux

14. Peristalsis Are involuntary waves of the glosopharyngeal nerves stimulated by the act of swallowing Secondary stimulation of peristalsis occurs with dilatation of the lower half of the esophaus

15. The Stomach Has 3 anatomic divisions: The fundus, lies above and to the left of the cardiac sphincter The body The antrum or pylorus

16. Sphincters Regulate inflow and outflow from the stomach. The cardiac sphincter at the proximal end of the stomach allows inflow of food and prevents backflow of material The pyloric sphincter lies between the distal end of the stomach and the duodenum permits the flow of chyme from the stomach

17. Stomach Has four layers Serous- the visceral peritoneum Muscular- produces peristaltic movements Submucous- contains blood, lymph and nerve plexuses Mucous-epithelial cells with microscopic glands

18. Chief cells- secrete mucus and pepsinogen Parietal cells- secrete hydrochloric acid, stimulated by gastrin. Also secrete the intrinsic factor Neck cells- secrete mucus Pyloric glands- secrete gastrin

19. Stomach Functions: Storage Mixing and liquefication of bolus into chyme Blood supply: celiac artery Drainage: portal vein

21. Results in increased secretion of gastrin and pepsin and increased gastric motor activity

22. The greater splanchic nerve and celiac ganglia- sympathetic innervation

24. Phases of gastric secretion Cephalic phase Stimulated by hunger, food odor, sight and smell Results secretion of acid pepsin and mucus Lasts for 30-4- minutes after eating

25. GASTRIC PHASE Occurs when the bolus of food reaches the antrum Gastrin stimulates parietal cells of the antrum to secrete hydrochloric acid Continues until the acidity of the gastric contents reaches 1.5 or less

26. INTESTINAL PHASE Stimulated by food entering the duodenum Duodenal pH gradually decreases resulting in the release of secretin that inhibits gastric secretion and slows gastric emptying

27. Gastric inhibition Secretions are decreased by: Vagal stimulation Fat Enterogastrones- secretin and cholecystokinin Alterations in blood flow Inflammation

28. Small Intestine 22 feet long, 1 inch in diameter Divided into 3 segments duodenum- 9.8 inches Jejunum- middle section,2.5 m Ileum- joins the colon through the ileoceccal valve,3.5

29. SMALL INTESTINES where most chemical digestion takes place. Most of the digestive enzymes that act in the small intestine are secreted by the pancreas The enzymes enter the small intestine in response to the hormone cholecystokinin, which is produced in the small intestine in response to the presence of nutrients. The hormone secretin also causes bicarbonate to be released into the small intestine from the pancreas in order to neutralize acid coming from the stomach.

30. Proteins and peptides are degraded into amino acids. Chemical breakdown begins in the stomach and continues in the small intestine. Proteolytic enzymes, including trypsin and chymotrypsin, are secreted by the pancreas and cleave proteins into smaller peptides.

31. Lipids (fats) are degraded into fatty acids and glycerol. Pancreatic lipase breaks down triglycerides into free fatty acids and monoglycerides. Pancreatic lipase works with the help of the salts from the bile secreted by the liver and the gall bladder

32. Carbohydrates are degraded into simple sugars, or monosaccharides Pancreatic amylase breaks down carbohydrates into oligosaccharides.

33. ABSORPTION the digested food can now pass into the blood vessels in the wall of the intestine through the process known as diffusion. The small intestine is the site where most of the nutrients from ingested food are absorbed.

34. The inner wall, or mucosa, of the small intestine is lined with simple columnar epithelial tissue. Structurally, the mucosa is covered in wrinkles or folds called plicaecirculares where microscopic finger-like pieces of tissue called villi project. The individual epithelial cells also have finger-like projections known as microvilli. The function of the plicaecirculares, the villi and the microvilli is to increase the amount of surface area available for the absorption of nutrients.

36. COLON simply absorbs vitamins that are created by the bacteria inhabiting the colon. It also absorbs water and compacts feces stores fecal matter in the rectum until eliminated through the anus and thus is responsible for passing along solid waste

37. houses over 700 species of bacteria that perform a variety of functions. These bacteria also produce large amounts of vitamins, especially vitamin K and Biotin for absorption into the blood.

38. RECTUM acts as a temporary storage facility for feces. As the rectal walls expand due to the materials filling it from within, stretch receptors from the nervous system located in the rectal walls stimulate the desire to defecate

39. ANUS the external opening of the rectum closure is controlled by sphincter muscle

40. intra-rectal pressure builds as the rectum fills with feces, pushing the feces against the walls of the anal canal. Contractions of abdominal and pelvic floor muscles can create intra-abdominal pressure which further increases intra-rectal pressure. The internal anal sphincter responds to the pressure by relaxing, thus allowing the feces to enter the canal. The rectum shortens as feces are pushed into the anal canal and peristaltic waves push the feces out of the rectum. Relaxation of the internal and external anal sphincters allows the feces to exit from the anus, finally, as the levatorani muscles pull the anus up over the exiting feces

41. ACCESSORY ORGANS

42. LIVER largest glandular organ with a weight of about 1.5 kg It is reddish brown organ with four lobes of unequal size and shape location: the right side of the abdominal cavity just below the diaphragm and is connected to two large blood vessels, the hepatic artery and the portal vein. Functional units: hepatocytes

43. Liver functions Protein/ amino acid synthesis Gluconeogenesis Glycogenolysis Glycogenesis Lipid metabolism Production of coagulation factors Production and secretion of bile major site of thrombopoietin production

44. The breakdown of insulin and other hormones The liver breaks down hemoglobin, creating metabolites that are added to bile as pigment The liver breaks down or modifies toxic substances and most medicinal products in a process called drug metabolism. The liver converts ammonia to urea.

45. The liver stores a multitude of substances, including glucose ,vitamin A,vitamin D, B12, iron and copper. The liver produces albumin, The liver synthesizes angiotensinogen

46. PANCREAS both an endocrine gland producing several important hormones, including insulin, glucagon, and somatostatin, as well as an exocrine gland secreting pancreatic juice containing digestive enzymes that pass to the small intestine

47. Made of two types of tissue: islets of Langerhans – endocrine function, hormone production and secretion Alpha cells-secrete glucagon Beta cells- secrete insulin Delta cells-secrete somatostatin

48. b. Acinar cells-digestive enzyme production Trypsin chymotrypsin pancreatic lipase pancreatic amylase

49. APPENDIX located near the junction of the small intestine and the large intestine or the cecum 10 cm in length, but can range from 2 to 20 cm Thought to be a vestigial structure

50. GALLBLADDER A pouch that stores bile temporarily stores about 50 mL of bile, which is released when food containing fat enters the digestive tract, stimulating the secretion of cholecystokinin bile, produced in the liver, emulsifies fats in partly digested food.

51. Bile bitter yellowish, blue and green fluid secreted by hepatocytes from the liver The main components include: Water Cholesterol Bile pigments Bile acids Phospholipids mainly lecithin Bicarbonate and other ions

52. Bile then flows into the common hepatic duct, which joins with the cystic duct from the gallbladder to form the common bile duct. The common bile duct in turn joins with the pancreatic duct to empty into the duodenum. If the sphincter of Oddi is closed, bile is prevented from draining into the intestine and instead flows into the gallbladder, where it is stored

53. Functions: Emulsification of fat absorption of the fat-soluble vitamins D, E, K and A route of excretion for the hemoglobin breakdown product

54. Assessment of the Gastrointestinal System Inspection Auscultation Percussion Palpation

55. Diagnostic Evaluation

56. Barium sulfate a chalky, radiopaque substance that allows fluoroscopy and x-ray examination of the GI system Stools may be light colored within 24-72 hours after intake. It may cause constipation

57. Upper GI series/Barium Swallow Permits the visualization of the esophagus, stomach duodenum and proximal jejunum Preparation: low residue diet , withhold anticholinergic drugs, NPO post midnight After swallowing barium, the patient assumes various positions on the x-ray table

58. Lower GI series/Barium Enema Used to diagnose disorders of the colon Preparation: low residue diet, NPO post midnight, laxative pre-procedure until the return flow is clear Tell the person may feel the urge to defecate

59. Endoscopy Is the direct visualization of the GI system by means of a lighted flexible tube.

60. Upper GI endoscopy Includes esophagoscopy, gastroscopygastroduodenescopy Preparation: NPO at least 6 hours Atropine sulfate may be given Sedatives and tranquilizers Dentures should be removed Local anesthetics may be given

61. Post-procedure Do not give food or water until gag reflex returns Anesthetic sprays or normal saline gargles may be given

62. Lower GI Endoscopy Is the visualization of the bowel through a proctoscope, sigmoidoscope or colonoscope

64. Fecal Analysis Stools are examined for chemical constituents, bacteria, parasites, lipids and occult blood Normal pH is between 6.8- 7.3 Contents include clcium, phosphates, carbohydrates, fat, nitrogen, protein, amylase, lipase, and trypsin It is brown and formed

65. FOR RLE GRADES ellarosenavarro@gmail.com

66. INTESTINAL TUBES

67. Reasons for placing intestinal tubes: Decompression of the GI tract (i.e. intestinal obstruction) Lavage (washing out the stomach) Gavage (feeding) Compression (control bleeding) Diagnosis (analysis of GI contents)

68. Levin (standard nasogastric tube)

69. Salem Sump (nasogastric tube with side ports)

70. Dobhoff/PEG (enteral feeding)

71. Sengstaken-Blakemore (compression of gastric cardia and distal esophagus to control variceal bleeding)

72. Long tubes (Miller-Abbott/Cantor)

73. Insertion Procedure for NG tube: Sit patient upright (preferable) Inspect nares, pick larger of the nares Lubricate NG tube Insert tube into back of nose with gentle pressure Ask patient to swallow, advance tube rapidly but gently (patient may sip water) Confirm placement of tube in stomach

74. DENTAL DISORDERS

75. Dental Disorders 1. dental plaque- a soft mass of proliferating bacteria with a scattering of leukocytes, macrophages in a polysaccharide-protein matrix that adheres to the teeth. It is usually undetectable unless it absorbs pigment within the cavity Prevention: tooth care

76. Dental Caries Or tooth decay, may be caused by resistance of the tooth enamel, plaque and bacteria Acid produced by bacteria in the teeth decalcify enamel when pH goes below 5.6 Treatment: removal of decayed teeth, restoration

77. Fillings Crowns-The decayed or weakened area is removed and repaired. A crown is fitted over the remainder of the tooth. Crowns are often made of gold, porcelain, or porcelain attached to metal. Root canals-The center of the tooth, including the nerve and blood vessel tissue (pulp), is removed along with decayed portions of the tooth. The roots are filled with a sealing material. The tooth is filled, and a crown may be placed over the tooth if needed.

78. Gingivitis and Periodontitis Gingivitis Inflammation of the gums/gingiva Presents with bleeding, alteration in the color , swelling and ulceration Periodontitis Inflammation extending to the alveolar bone and ligament There is bleeding, swelling and breath odor

79. treatment Reduce inflammation, Tooth cleaning Antibacterial mouthwash Emphasize oral hygiene

80. Stomatitis inflammation of the mouth. May be caused by a chemical or mechanical trauma, chemotherapy Management: Removal of cause, soft bland diet, topical medication, oral hygiene

81. Aphthous Stomatitis Or canker sores, are ulcers that form in the soft tissues of the mouth May be caused by emotional stress, trauma, vitamin deficiency, drug allergy or endocrine imbalance Management: topical steroids, oral hygiene

82. Actinic cheilitis also known as solar cheilitis, sailor's lip, or farmer's lip, is a form of cheilitis which is the counterpart of actinic keratosis of the skin and can develop into squamous cell carcinoma. there is thickening whitish discoloration of the lip at the border of the lip and skin. There is also a loss of the usually sharp border between the red of the lip and the normal skin, known as the vermillion border. The lip may become scaly and indurated the lesion is usually painless, persistent,

85. symptoms Location Usually on the tongue May be on the inside of the cheeks In females, occasionally on the genitals Color Usually white or gray May be red (called erythroplakia, a condition that can lead to cancer) Texture Thick Slightly raised Hardened surface

86. Treatment Goal of treatment is to get rid of the lesion. Removing the source of irritation is important and may cause the lesion to disappear. Treat dental causes such as rough teeth, irregular denture surface, or fillings as soon as possible. Stop smoking or using other tobacco products. Do not drink alcohol. Surgery to remove the lesion

87. HIATAL HERNIA

88. Hiatal Hernia Is the protrusion of the stomach upward into the mediastinal cavity through the esophageal hiatus of the diaphragm Commonly caused by trauma or weakness due to loss of muscle tone which results to regurgitation and motor dysfunction

89. Symptoms Heartburn Regurgitation Dysphagia Dull, heavy bloating pain

90. Diagnosis Barium swallow Esophagoscopy Motility studies

91. Management Prevent symptoms by keeping acidic acidic pepsin and alkaline biliary secretions from contacting the esophagus 1.Avoid bending, lifting, coughing, vomiting or straining 2. Eat food with more fiber 3. Stop/decrease smoking 4.Wear non-constrictive clothing

92. 5. Eat small but frequent meals 6.Avoid highly seasoned food 7. Eat in a sitting position 8. Avoid reclining or lying down after a meal

93. Surgical Management Aim:to restore the hernia below the diaphragm, narrow the esophageal hiatus, and stop reflux Procedure: Nissenfundoplication, Hill operation, Belsey. Postoperatively: assess for dysphagia, early satiety, epigastric fullness, leakage into tube due to improper placement

95. GASTRITIS

96. Gastritis Or gastric inflammation often occurs with nausea, vomiting, discomfort, malaise, anorexia May be caused by ingestion of corrosive, erosive or infectious substance, alcohol, Usually of short duration Diagnosis: history, gastroscopic examination Management: Symptomatic treatment Antacids Electrolyte replacement if severe

97. ACHALASIA

98. Achalasia esophageal motility disorder wherein the smooth muscle layer of the esophagus loses normal peristalsis and the lower esophageal sphincter (LES) fails to relax properly in response to swallowing Causes include: Cancers Damage to the nerves of the esophagus Infection with a parasite Inherited factors

99. Symptoms difficulty swallowing, regurgitation and sometimes chest pain weight loss, coughing when lying in a horizontal position, chest pain which may be perceived as heartburn

100. diagnosis Barium swallow Esophageal manometry Endoscopy

101. Treatment/management Eating small, frequent feedings Nifedipine-decreases LES pressure Lifestyle changes: raising the head of the bed, avoiding spicy food, caffeinated beverages Botulinum toxin –paralyzes the LES Pneumatic dilation-muscle fibers are stretched and slightly torn by forceful inflation of a balloon placed inside the lower esophageal sphincter. Surgery-Heller myotomy, lengthwise cut along the esophagus, starting above the LES and extending down onto the stomach a little way, partial fundoplication or "wrap" is generally added in order to prevent excessive reflux,

103. DIVERTICULOSIS

104. diverticulosis Refers to the presence of noninflammed pouches in the gastrointestinal tract

105. Diverticulitis Inflammation of a diverticulum. It is a blind outpouching of intestinal mucosa through the muscular coat. It is common to both men and women, in ages 45 years and above and obese When fecaliths enter the divercula, and do not liquefy they may become trapped and cause irritation and inflammation

106. Symptoms Episodic, dull, left quadrant, mid-abdominal pain Changes in bowel habits Increased flatus Anorexia Low grade fever Rectal bleeding

107. Management Colonic rest Avoid activities that increase intra abdominal pressure Increase oral fluid intake Reduction of weight

108. APPENDICITIS

110. Appendicitis Inflammation of the appendix May be caused by fecaliths, kinking of the appendix, swelling of the bowel wall, Commonly occurs in both sexes and in adolescents and young adults

111. Symptoms Begins with abdominal discomfort which comes in waves that start in the epigastrium or periumbilical region then shifts to right lower quadrant when the inflammatory process spreads to serosal layers of the bowel Pain then becomes steady at mcburney’s point, which is midway between the anterior superior iliac crest and umbilicus Vomiting, low grade fever, mild leukocytosis

112. Management Removal of the appendix within 24-48 hours after onset of symptoms Appendectomy

113. ULCERS

114. Peptic Ulcers Is a break in the continuity of GI mucosa, it may occur in any part of the tract that comes in contact with gastric juices Etiology: hypersecretion of gastric juice, loss of mucosal integrity, inability of the regulators to inhibit gastric secretion, emotional stress, medications, hormones and chemical ingestions Has two types: Duodenal and Gastric

115. Duodenal Ulcer Have higher incidences than gastric ulcers Characterized by high gastric cid secretion attributed to a greater mass of parietal cells Patients empty their stomach more rapidly

116. etiology Helicobacter pylori infection Altered gastric acid levels Smoking and alcohol Aspirin and NSAIDS Genetic predisposition Stress, chronic anxiety, type A personality

117. Duodenal Ulcer Burning, aching, gnawing pain at the right epigastrium Pain occurs 2-3 hours after meals Causes patient to awaken at night Pain relieved by eating Epigastric tenderness

118. Gastric Ulcer Pain location: upper epigastrium Burning, aching, gnawing pain 30 minutes to 1 hour after meals Worsened by intake of food Epigastric tenderness

119. Diagnosis Endoscopy History Biopsy

120. Complications Hemorrhage Gastric perforation shock

121. Stress Ulcers Occur after an acute medical crisis Curling’s Ulcer- after severe burns Cushing’s Ulcer- after a head injury or intrcranial disease Zollinger-Ellison syndrome -a disorder where increased levels of the hormone gastrin are produced, causing the stomach to produce excess hydrochloric acid.

122. Management Aim: promote stomach rest by neutralizing the hydrochloric acid, inhibiting acid secretion and protect the mucosa Pharmacologic mangement: Anticholinergics Prostaglandin analogs Histamine antagonists Proton pump inhibitors

123. Surgical Management Vagotomy-to eliminate the acid-stimulus to gastric cells Antrectomy/ Billroth I & II- to reduce acid secreting portions of the stomach Nursing Responsibilities: Watch out for complications such s hemorrhage and dumping syndrome Check drainage of tubes, do not irrigate unless indicated

124. INFLAMMATORY BOWEL DISEASE

125. Inflammatory bowel disease Includes both regional enteritis and ulcerative colitis Characterized by exacerbations and remissions and are chronic, recurrent Common in young adults May be trigerred by pesticides, food additives, tobacco, radiation, heredity

126. REGIONAL ENTERITIS Also called Crohn’s disease, a chronic relapsing disease that develop in any segment of the GI tract. Its most common site is the terminal ileum Its cause is unknown, but may have genetic basis Lesions develop in separated segments of the bowel that are grossly visible and sharply demarcated inflammation, of all layers of the bowel wall of the intestinal mucosa

127. Symptoms Enlarged lymph nodes Apperance of peyer’s patches Fistulas and abscess formation Abdominal tenderness Pain that is colicky Diarrhea, flatulence and steatorrhea Diagnosis: “string sign” seen on xray after barium enema