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Nutrition: Week Eight
Chapter 13: Nutrition for Gastrointestinal Disorders
Nurses must gain an awareness of nutritional needs for clients who have gastrointestinal disorders. It is important to explore dietary needs with the client and recommend modifications in relationship to the disease process. Understanding the role of primary and secondary prevention is essential to successful treatment.
Nutrition therapy for GI disorders is generally aimed at minimizing or preventing manifestations. In some conditions (celiac disease), nutrition is the only treatment. For some GI disorders, nutrition therapy is the foundation of treatment.
Assessment/Data Collection
Determine whether the client is experiencing any of the following.
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Difficulty chewing or swallowing
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Nausea, vomiting, or diarrhea
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Bloating, excessive flatus, occult blood, steatorrhea, abdominal pain or cramping, abdominal distention, pale, sticky bowel movements.
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Changes in body weight, eating patterns, or bowel habits.
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Determine whether the client uses the following.
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Tobacco
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Alcohol
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Caffeine
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Over-the-counter meds to treat GI conditions
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Nutritional supplements
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Herbal supplements for GI conditions or other problems.
Nutritional Guidelines and Nursing Interventions-
General Gastrointestinal Considerations
Monitor GI parameters
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Weight and weight changes
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Laboratory values
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Elimination patterns
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I & O
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Low-fiber diets avoid foods that are high in residue content (whole-grain breads and cereals, raw fruits and vegetables.
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Diets low in fiber reduce the frequency and volume of fecal output and slow transit time of food through the digestive tract.
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Low-fiber diets are used short-term for clients who have diarrhea or malabsorption syndromes.
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High-fiber diets focus on foods containing more than 5 g of fiber per serving. A diet high in fiber helps:
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Increase stool bulk
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Stimulate peristalsis
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Prevent constipation
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Protect against colon cancer
Nutritional Guidelines and Nursing Interventions-
Nausea & Vomiting
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Potential causes of nausea and vomiting include decreased gastric acid secretion; decreased gastrointestinal motility; allergy to food(s); bacterial or viral infection; increased intracranial pressure; liver, pancreatic, and gall bladder disorders; adverse effects of some medications.
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The underlying cause of nausea and vomiting should be investigated. Assessing the appearance of the emesis will aid in diagnosis and treatment (coffee-ground emesis indicates the presence of blood; pale green indicates bile).
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Once manifestations subside, begin with clear liquids followed by full liquids, and advance the diet as tolerated.
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Easy-to-digest, low-fat carbohydrate foods (crackers, toast, oatmeal, pretzels, plain bread, bland fruit) are usually well-tolerated.
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NURSING ACTIONS
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Promote good oral hygiene with tooth brushing, mouth swabs, mouthwash, and ice chips.
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Elevate the head of the bed.
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Serve foods at room temperature or chilled.
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CLIENT EDUCATION
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Avoid hot and spicy foods.
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Avoid liquids with meals, as they promote a feeling of fullness.
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Avoid high-fat foods if they contribute to nausea because they are difficult to digest.
Nutritional Guidelines and Nursing Interventions-
Anorexia
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Anorexia is defined as a lack of appetite. It is a common finding for numerous physical conditions and is an adverse effect of certain meds. It is not the same as anorexia nervosa.
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Anorexia can lead to decreased nutritional intake and subsequent protein and calorie deficits.
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NURSING ACTIONS
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Decrease stress at mealtimes.
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Collect data regarding adverse effects of medications.
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Admin meds to stimulate appetite.
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Assess and modify environment for unpleasant odors.
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Remove items that cause a decrease in appetite.
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Assess and manage anxiety and depression.
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Provide small, frequent meals to prevent the client from feeling full before adequate intake of calories from food.
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Provide liquid supplements between meals to improve protein and calorie intake.
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Ensure that meals appear appealing. Serve large meals early in the day.
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Assess for changes in bowel status
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Position to increase gastric motility.
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Provide mouth care before and after meals.
Nutritional Guidelines and Nursing Interventions-
Constipation
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Clients who have constipation have difficult or infrequent passage of stools, which can be hard and dry.
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Causes include irregular bowel syndrome, pregnancy, or secondary to genital/rectal trauma, and inadequate consumption of fiber and fluid.
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Encourage exercise and a diet high in fiber (25 g/day for females and 38 g/day for males) and promote adequate fluid intake to help alleviate constipation.
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If caused by medication, a change in the medication might be necessary.
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NURSING ACTIONS
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Determine onset and duration of past and present elimination patterns, what is normal for the client, activity levels, occupation, dietary intake, and stress levels.
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Collect data about past medical and surgical history, medication use, presence of rectal pressure or fullness, and abdominal pain.
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Encourage client to gradually increase daily fiber intake.
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CLIENT EDUCATION
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Increase fluid intake to 64 oz/day unless contraindicated.
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An increase in fiber intake is the preferred treatment for constipation. Avoid chronic use of laxatives.
Nutritional Guidelines and Nursing Interventions-
Diarrhea
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Diarrhea can cause significant losses of potassium, sodium, and fluid, as well as nutritional complications.
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Common causes of diarrhea include emotional and physical stress, GI disorders, malabsorption disorders, infections, and certain meds.
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Low-fiber diets might be recommended on a short-term basis to decrease bowel stimulation.
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Nutrition therapy varies with the severity and duration of diarrhea. A liberal fluid intake to replace losses is needed.
Nutritional Guidelines and Nursing Interventions-
Dysphagia
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Dysphagia is an alteration in the client’s ability to swallow.
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Causes include obstruction, inflammation, and certain neurologic disorders.
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Modifying the texture of foods and the consistency of liquids can enable the client to achieve proper nutrition.
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Dry mouth can contribute to dysphagia. Evaluate meds being taken to determine if this is a potential adverse effect.
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Clients who have dysphagia should be referred to a speech therapist for evaluation.
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Dietary modifications are based on the specific swallowing limitations experienced by the client.
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Nutritional supplements are beneficial if nutritional intake is deemed inadequate.
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NURSING ACTIONS
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Clients who have dysphagia are at an increased risk of aspiration. Place the client in an upright or high-Fowler’s position to facilitate swallowing.
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Provide oral care prior to eating to enhance the client’s sense of taste.
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Allow adequate time for eating, use adaptive eating devices, and encourage small bites and thorough chewing.
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CLIENT EDUCATION
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Pills should be taken with at least 8 oz of fluid (can be thickened) to prevent medication from remaining in the esophagus.
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Avoid thin liquids and sticky foods.
Nutritional Guidelines and Nursing Interventions-
Dumping Syndrome
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Normally, the stomach controls the rate in which nutrients enter the small intestine. When a portion of the stomach is surgically removed, the contents of the stomach are rapidly emptied into the small intestine, causing dumping syndrome.
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Early manifestations typically occur 10 to 20 min after eating, and include a sensation of fullness, abdominal cramping, nausea, diarrhea, and vasomotor manifestations (faintness, syncope, diaphoresis, tachycardia, hypotension, flushing).
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Late manifestations occur 1 to 3 hr. after eating and include diaphoresis, weakness, tremors, anxiety, nausea, and hunger. Manifestations should resolve after intestine is emptied. However, there is a rapid rise in blood glucose and increase in insulin levels immediately after the intestine empties, leading to hypoglycemia.
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NURSING ACTIONS
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Monitor clients receiving enteral tube feedings and report manifestations of dumping syndrome to the provider.
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Monitor the client for vitamin and mineral deficits (iron, Vit B12)
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CLIENT EDUCATION
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Consume small, frequent meals.
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Consume protein and fat at each meal.
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Avoid food that contains concentrated sugars and restrict lactose intake.
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Plan to consume liquids 1 hr. after meals or between meals.
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Lie down after meals to delay gastric emptying. If reflux is a problem, try a reclining position.
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nutrition for
Gastrointestinal disorders
Nutritional Guidelines and Nursing Interventions-
Gastroesophageal Reflux Disease
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GERD occurs as the result of the abnormal reflux of secretions up the esophagus. This leads to indigestion and heartburn.
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Factors that contribute to GERD include hiatal hernia, obesity, pregnancy, smoking, some meds, and genetics.
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Long-term GERD can cause serious complications, including adenocarcinoma of the esophagus and Barrett’s esophagus.
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Manifestations include heartburn, retrosternal burning, painful swallowing, dyspepsia, regurgitation, coughing, hoarseness, and epigastric pain. Pain can be mistaken for a MI.
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CLIENT EDUCATION
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Avoid situations that lead to increased abdominal pressure, such as wearing tight-fitting clothing.
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Avoid eating for 3 hr before lying down.
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Elevate the body on pillows instead of lying flat and avoid large meals and bedtime snacks.
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Attempt weight loss if overweight or obese.
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Avoid trigger foods (citrus fruits and juices, spicy foods, carbonated beverages).
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Avoid items that reduce lower esophageal sphincter pressure (fatty foods, caffeine, chocolate, alcohol, cig smoke, all nicotine products, peppermint and spearmint flavors).
Nutritional Guidelines and Nursing Interventions-
Acute and Chronic Gastritis
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Gastritis is characterized by inflammation of the gastric mucosa. The gastric mucosa is congested with blood and fluid, becoming inflamed. There is a decrease in acid produced and an overabundance of mucus. Superficial ulcers occur, sometimes leading to hemorrhages.
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Acute gastritis occurs with excessive use of NSAIDs, bile reflux, ingestion of a strong acid or alkali substance, as a complication of radiation therapy, or as a complication of trauma (burns; food poisoning; severe infection; liver, kidney, or respiratory failure; major surgery).
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Chronic gastritis occurs in the presence of ulcers, Helicobacter pylori, autoimmune disorders (pernicious anemia), poor diet, meds, and reflux of pancreatic secretions and bile into stomach.
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Manifestations include abdominal pain or discomfort (can be relieved by eating), headache, lethargy, nausea, anorexia, hiccupping (lasting a few hrs to days), heartburn after eating, belching, sour taste in mouth, vomiting, bleeding, and hematemesis. Acute recovery typically occurs in 1 day but can take 2-3 days. The client should eat a bland diet when able to tolerate food. IV fluid replacement therapy is indicated if the condition persists.
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When the condition occurs due to ingestion of strong acids or alkalis, dilution and neutralization of the causal agent is needed. Avoid lavage and emetics due to potential perforation and esophageal damage.
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CHRONIC MANAGEMENT:
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modify diet, reduce and manage stress, avoid alcohol and NSAIDs. If condition is persistent, the provider will prescribe an H2 receptor antagonist (ranitidine).
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NURSING ACTIONS:
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monitor for vit deficiency, especially vit B12.
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CLIENT EDUCATION:
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Avoid eating frequent meals and snacks, as they promote increased gastric acid secretion.
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Avoid alcohol, cig smoking, aspirin and other NSAIDs, coffee, black pepper, spicy foods.
Nutritional Guidelines and Nursing Interventions-
Peptic Ulcer Disease
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Peptic ulcer disease (PUD) is characterized by an erosion of the mucosal layer of the stomach or duodenum, this can be caused by a bacterial infection with H. pylori or the chronic use of NSAIDs.
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Some clients who have PUD do not experience manifestations. Others report dull, gnawing pain, burning sensation in the back or low mid-epigastric area, heartburn, constipation or diarrhea, sour taste in mouth, burping, nausea, vomiting, bloating, urea present in breath, and tarry stools. Eating can temporarily relieve pain. Anemia can occur due to blood loss.
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For PUD caused by H. Pylori, the provider prescribes triple therapy (a combination of antibiotics and acid reducing meds) to be taken for 10 to 14 days.
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CLIENT EDUCATION:
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avoid coffee, alcohol, caffeine, aspirin and other NSAIDs, cig smoking, black pepper, and spicy foods.
Nutritional Guidelines and Nursing Interventions-
Lactose Intolerance
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Lactose intolerance results from an inadequate supply of lactase in the intestine, the enzyme that digests lactose.
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The enzyme that converts lactose into glucose, and galactose is absent or insufficient. Manifestations include distention, cramps, flatus, and osmotic diarrhea.
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Small amounts (4 to 6 oz) of milk taken during meals can be tolerated.
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Some dairy products (yogurt, aged cheeses) are low in lactate and can be tolerated.
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NURSING ACTIONS:
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Monitor for vitamin D and calcium deficiency. Avoid or limit intake of foods high in lactose (milk, soft cheese, ice cream, cream soups, sour cream, puddings, coffee creamer). Ask provider about the use of a lactase enzyme.
Nutritional Guidelines and Nursing Interventions-
Ileostomies and Colostomies
An ostomy is a surgically created opening on the surface of the abdomen from either the end of the small intestine or from the colon.
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Fluid and electrolyte maintenance is the primary concern for clients who have ileostomies and colostomies.
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The colon absorbs large amounts of fluid, sodium, and potassium.
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Nutrition therapy begins with liquids only and is slowly advanced based upon client tolerance.
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NURSING ACTIONS:
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provide emotional support to clients due to the risk of altered body image.
CLIENT EDUCATION:
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Consume a diet that is high in fluids and solube fiber.
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Avoid foods that cause gas, stomal blockage and foods that produce odor.
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Increase intake of calories and protein to promote healing of the stoma site.
Nutritional Guidelines and Nursing Interventions-
Diverticulosis and Diverticulitis
Diverticula are pouches protruding through the muscle of the intestinal wall, usually from increased intraluminal pressure. They occur anywhere in the colon, but usually in the sigmoid colon. Unless infection occurs, diverticula cause no problems.
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Diverticulosis is a condition characterized by the presence of diverticula.
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Diverticulitis is inflammation that occurs qhen fecal matter becomes trapped.
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Manifestations include abdominal pain, nausea, vomiting, constipation or diarrhea, and fever, accompanied by chills and tachycardia.
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The client receives antibiotics, anticholinergics, and analgesics. Clients who have severe manifestations are admitted to the hospital and dehydration is treated with IV therapy. Opioid analgesics are administered for pain. Complications (peritonitis, bowel obstruction, abscess) can warrant surgical intervention.
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A high-fiber diet can prevent by producing stools that are easily passes, thus decreasing pressure.
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During acute diverticulitis, a clear liquid diet is prescribed until inflammation decreases, then a high-fiber, low-fat diet is indicated.
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Clients require instruction regarding diet adjustment based on the need for an acute intervention or preventative approach.
Nutritional Guidelines and Nursing Interventions-
Inflammatory Bowel Disease (IBD)
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Crohn’s disease and ulcerative colitis are chronic, inflammatory bowel diseases characterized by periods of exacerbation and remission.
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Manifestations include nausea, vomiting, abdominal cramps, fever, fatigue, anorexia, weight loss, steatorrhea, and low-grade fever.
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Nutrition therapy is focused on providing nutrients in forms that the client can tolerate.
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A low-residue, high-protein, high-calorie diet with vitamin and mineral supplementation is prescribed during exacerbations to minimize bowel stimulation. Fluid and electrolyte inbalances are corrected with IV fluids or oral replacement fluids.
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Enteral nutrition can be prescribed during exacerbations, especially if the client is reluctant to eat.
Nutritional Guidelines and Nursing Interventions-
Cholecystitis
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Characterized by inflammation of gallbladder.
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Manifestations include pain, tenderness, and rigidity in the upper right abdomen. Can radiate to the right shoulder or midsternal area. Nausea, vomiting, and anorexia can also occur. If the gallbladder becomes filled with pus or becomes gangrenous, perforation can result.
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Clients who have large stones or inability to control the condition with diet modifications need surgery.
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Fat intake should be limited to reduce stimulation of the gall bladder
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The diet is individualized to the client’s needs and tolerance.
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Nutrition for
Gastrointestinal disorders
