Adult Health Exam 3
GI Changes with Aging – Stomach
Atrophy of Gastric Mucosa
Decrease in hydrochloric acid levels
- Decreased absorption of iron and vitamin B12
- Proliferation of bacteria
- Atrophic gastritis occurs as a consequence of bacterial overgrowth
Encourage bland foods & iron and B12
Assess epigastric pain
GI Changes with Aging – Intestine
Peristalsis decreases
Nerve impulses are dulled
Decreased sensation to defecate can result in postponement of bowel movements
- Leads to constipation and impaction
high fiber a fluid
activity !
GI Changes with Aging – Pancreas
Distension and dilation of pancreatic ducts
Calcification of pancreatic vessels occurs with a decrease in lipase production
- Decreased lipase level results in decreased fat absorption and digestion
- Excess fat in the feces (steatorrhea)occurs because of decreased fat digestion
small ,
frequent meals
GI Changes with Aging – Liver
Decrease in the number and size of hepatic cells and increase in fibrous tissue
- Leads to decreased protein synthesis and changes in liver enzymes
- Depresses drug metabolism – leads to accumulation of drugs, possibly to toxic levels
Assess AE of meds /toxicity ?)
Assessment – History and Physical Assessment
Patient history
Nutrition history
- Diet and food allergies
IMPORTANT:
- Anorexia and N/V
- Changes in taste
- Pain or difficulty swallowing
- Abdominal pain or discomfort with eating
- Dyspepsia – indigestion or heartburn
- Unintentional weight loss
- Alcohol and caffeine consumption
Family history and genetic risk
Current health problems
- Change in bowel habits
- Unintentional weight gain or loss
- Pain
- Changes in the skin due toalterations to
o
Discoloration or rashes, itching, jaundice, increased bruising, increased tendency to bleed
Physical assessment of abdomen
, - Inspection, Auscultation, Light Palpation, Percussion
- If appendicitis or an abdominal aneurysm is suspected, palpation is not done
Psychosocial assessment
- Stress can exacerbate some gastrointestinal disorders
Assessment – Labs
Liver Function Tests (liver enzymes)
- Alanine aminotransferase-ALT (4-36 units/L)
o Increased values may indicate liver disease, hepatitis, cirrhosis
- Aspartate aminotransferase–AST (0-35 units/L)
e o Increased values may indicate liver disease, hepatitis, cirrhosis
- Alkaline phosphatase-ALK (30-120 units/L)
o Increased values may indicate cirrhosis, biliary obstruction, liver tumor
yellow
tone
Bilirubin (0.3-1.0 mg/dL) – Increased values may indicate hemolysis, biliary obstruction, hepatic damage
Albumin (3.5-5) – Decreased values may indicate hepatic disease
Ammonia (10-80 mg/dL) – Increased values may indicate hepatic disease such as cirrhosis
colon
cancer, Ca 19-9 and CEA – Evaluated to diagnose cancer and could be increased in benign GI conditions
Serum amylase (30-220 units/L) – Increased values may indicate acute pancreatitis
Serum lipase (0-160 units/L) – Increased values may indicate acute pancreatitis
Prothrombin time (PT) (11-12.5 sec) – Useful in evaluating clotting, if elevated could indicate hepatic issue
Electrolytes
- Calcium (9-10.5) – Decreased values may indicate malabsorption, kidney failure, acute pancreatitis
- Potassium (3.5-5) – Decreased values may indicate vomiting, gastric suctioning, diarrhea, drainage from
intestinal fistulas
CBC – Low Hbg/Hct could indicate anemia with GI bleeding; elevated WBC could indicate infection
Stool – Annual guaiac heme fecal occult blood test (gFOBT) or fecal immunochemical test (FIT) to detect colorectal
cancer
- Ova and parasites – aid in diagnosis of parasitic infection, fecal fats, cytotoxic assay or culture
Assessment – Diagnostic Tests
Imaging Tests:
- Abdominal x-ray – can identify tumors, strictures, and obstructions
- Acute abdominal series – includes chest x-ray, supine and upright abdominal x-ray
- Abdominal computerized tomography (CT)
- Abdominal magnetic resonance imaging (MRI)
- Upper GI series (Barium Swallow) – X-ray from mouth to duodenojejunal junctions with use of barium -
risk for
FLUIDS
constipation
GIVE
- Small bowel follow-through – extension of the upper GI x-ray with use of barium
- Barium enema – X-ray of large intestine with use of barium
- Percutaneous transhepatic cholangiography (PTC) – examines biliary duct system using iodine dye
- Magnetic resonance cholangiopancreatography (MRCP)
Esophagogastroduodenoscopy (EGD)
- Visual exam of the esophagus, stomach, duodenum with use of fiberoptic scope
- Preparation: NPO for 6-8 hours and avoid anticoagulants, aspirin, NSAIDS several days before procedure
- Procedure: Moderate sedation and lasts about 20-30 minutes
- Post procedure:
o Keep patient NPO until gag reflex returns
o Priority care includes preventing aspiration and assess for any bleeding or pain that could
indicate perforation
Endoscopic retrograde cholangiopancreatography (ERCP)
- Visual and radiographic exam of the liver, gallbladder, bile ducts, and pancreas
, - Use radiopaque dye
- Used to diagnose obstruction as well as treat obstructions
- Preparation: NPO for 6-8 hours and typically avoid anticoagulants as determined by provider
- Procedure: Moderate sedation and lasts 30 minutes to 2 hours
- Post procedure:
o Keep patient NPO until gag reflex returns
o Priority care includes preventing aspiration and assess for any bleeding or pain that could
indicate perforation
o Assess for gallbladder inflammation and pancreatitis- severe abdominal pain, nausea and
vomiting, fever, and elevated lipase
Small bowel endoscopy (enteroscopy)
- Provides a visual view of the small intestine
- Used to evaluate and locate source of GI bleeding
- Preparation:
o NPO except water for 8-10 hours then complete NPO for 2 hours before swallowing capsule
-
- Procedure:
o Sensors are placed on abdomen and patient wears a data recorder
o Patient swallows the capsule endoscope and can resume normal activity
o Patient may eat 4 hours after swallowing the capsule
o Procedure lasts 8 hours
- Post procedure:
o Explain to the patient that the capsule endoscope is excreted naturally and will be seen in the
stool
Colonoscopy
- Endoscopic exam of the entire large intestine – can be used to visually diagnose, biopsy and treat
- Baseline test should be done at age 50 and every 10 years
- Preparation:
o Clear liquids the day before
o NPO 4-6 hours prior
o Avoid aspirin, anticoagulants, and antiplatelet drugs for
several days before
o Adequate bowel cleansing is essential – follow provider orders for oral and rectal preparation;
Patient should be passing clear liquid prior to procedure
- Procedure: Moderate sedation and procedure lasts 30-60 minutes
- Post procedure:
o Observe for signs of perforation (severe pain) and hemorrhage
o Feelings of fullness and cramping are expected
o Fluids are permitted after the patient passes flatus to indicate that peristalsis has returned
Stomatitis
Inflammation within the oral cavity
- Painful single or multiple ulcerations that appear as inflammation and erosion of the protective lining of the
mouth; sores cause pain and open areas place the person at risk for bleeding and infection
- Mild erythema (redness) may respond to topical treatments
, - Extensive stomatitis may require treatment with systemic analgesics or medications
Causes:
- Infection – bacteria and viruses have a role in recurrent stomatitis
- Allergies – certain foods, such as coffee, potatoes, cheese, nuts, citrus fruits, and gluten may trigger allergic
responses that cause aphthous ulcers
- Vitamin deficiency – B vitamins, folate, zinc, iron
- Systemic disease and immunosuppression
- Irritants – tobacco and alcohol
Assessment:
- History of recent infections
- Nutritional changes
- Oral hygiene habits or oral trauma
- Stress
- Drug history
- If lesions are seen along the pharynx and the patient reports painful swallowing, the lesions might extend
down the esophagus
Interventions:
- Remove dentures
- Encourage or provide oral hygiene after each meal and as often as needed
- Increase oral care to every 2 hours or more
- Use a soft toothbrush or gauze
- Encourage frequent rinsing of the mouth with warm saline or baking soda solution
- Avoid commercial mouthwashes, specifically ones with alcohol and lemon/glycerin
- Assist with food choices
o Soft, bland, and nonacidic foods can decrease irritation; cool food can be soothing
Drug therapy:
- Antimicrobials for control of infection
o Ex. Tetracycline, Minocycline, chlorhexidine mouthwashes
- Herpes simplex
o IV Acyclovir (Zovirax) if severe or with immunocompromised patient; can be given oral or
topical
- Fungal infections/Yeast
o Nystatin (Mycostatin) swish/swallow
- Pain control
o Anesthetics; ex. Orabase, Anbesol, Campho-Phenique
Oral Cancer
Squamous cell carcinoma -
most common
- Oral lesions appear as red, raised, eroded areas on the lips, tongue, buccal mucosa, and oropharynx
- 90% of oral cancers – major risk factors are increasing age, tobacco use, alcohol use
Basal cell carcinoma
- Oral lesion is asymptomatic and resembles a raised scab – occurs primarily on the lips
- Lesion evolves into a characteristic ulcer with a raised, pearly border
- Major risk factor is excessive sunlight exposure
Kaposi’s Sarcoma
- Malignant lesion in blood vessels – usually painless and appears as a raised, purple nodule or plaque
- Most common site is the hard palate but can be found on the gums, tongue, or tonsils
- Most often associated with AIDS
Clinical Manifestations
- Bleeding from the mouth, poor appetite, difficulty chewing, difficulty swallowing, poor nutritional status and
GI Changes with Aging – Stomach
Atrophy of Gastric Mucosa
Decrease in hydrochloric acid levels
- Decreased absorption of iron and vitamin B12
- Proliferation of bacteria
- Atrophic gastritis occurs as a consequence of bacterial overgrowth
Encourage bland foods & iron and B12
Assess epigastric pain
GI Changes with Aging – Intestine
Peristalsis decreases
Nerve impulses are dulled
Decreased sensation to defecate can result in postponement of bowel movements
- Leads to constipation and impaction
high fiber a fluid
activity !
GI Changes with Aging – Pancreas
Distension and dilation of pancreatic ducts
Calcification of pancreatic vessels occurs with a decrease in lipase production
- Decreased lipase level results in decreased fat absorption and digestion
- Excess fat in the feces (steatorrhea)occurs because of decreased fat digestion
small ,
frequent meals
GI Changes with Aging – Liver
Decrease in the number and size of hepatic cells and increase in fibrous tissue
- Leads to decreased protein synthesis and changes in liver enzymes
- Depresses drug metabolism – leads to accumulation of drugs, possibly to toxic levels
Assess AE of meds /toxicity ?)
Assessment – History and Physical Assessment
Patient history
Nutrition history
- Diet and food allergies
IMPORTANT:
- Anorexia and N/V
- Changes in taste
- Pain or difficulty swallowing
- Abdominal pain or discomfort with eating
- Dyspepsia – indigestion or heartburn
- Unintentional weight loss
- Alcohol and caffeine consumption
Family history and genetic risk
Current health problems
- Change in bowel habits
- Unintentional weight gain or loss
- Pain
- Changes in the skin due toalterations to
o
Discoloration or rashes, itching, jaundice, increased bruising, increased tendency to bleed
Physical assessment of abdomen
, - Inspection, Auscultation, Light Palpation, Percussion
- If appendicitis or an abdominal aneurysm is suspected, palpation is not done
Psychosocial assessment
- Stress can exacerbate some gastrointestinal disorders
Assessment – Labs
Liver Function Tests (liver enzymes)
- Alanine aminotransferase-ALT (4-36 units/L)
o Increased values may indicate liver disease, hepatitis, cirrhosis
- Aspartate aminotransferase–AST (0-35 units/L)
e o Increased values may indicate liver disease, hepatitis, cirrhosis
- Alkaline phosphatase-ALK (30-120 units/L)
o Increased values may indicate cirrhosis, biliary obstruction, liver tumor
yellow
tone
Bilirubin (0.3-1.0 mg/dL) – Increased values may indicate hemolysis, biliary obstruction, hepatic damage
Albumin (3.5-5) – Decreased values may indicate hepatic disease
Ammonia (10-80 mg/dL) – Increased values may indicate hepatic disease such as cirrhosis
colon
cancer, Ca 19-9 and CEA – Evaluated to diagnose cancer and could be increased in benign GI conditions
Serum amylase (30-220 units/L) – Increased values may indicate acute pancreatitis
Serum lipase (0-160 units/L) – Increased values may indicate acute pancreatitis
Prothrombin time (PT) (11-12.5 sec) – Useful in evaluating clotting, if elevated could indicate hepatic issue
Electrolytes
- Calcium (9-10.5) – Decreased values may indicate malabsorption, kidney failure, acute pancreatitis
- Potassium (3.5-5) – Decreased values may indicate vomiting, gastric suctioning, diarrhea, drainage from
intestinal fistulas
CBC – Low Hbg/Hct could indicate anemia with GI bleeding; elevated WBC could indicate infection
Stool – Annual guaiac heme fecal occult blood test (gFOBT) or fecal immunochemical test (FIT) to detect colorectal
cancer
- Ova and parasites – aid in diagnosis of parasitic infection, fecal fats, cytotoxic assay or culture
Assessment – Diagnostic Tests
Imaging Tests:
- Abdominal x-ray – can identify tumors, strictures, and obstructions
- Acute abdominal series – includes chest x-ray, supine and upright abdominal x-ray
- Abdominal computerized tomography (CT)
- Abdominal magnetic resonance imaging (MRI)
- Upper GI series (Barium Swallow) – X-ray from mouth to duodenojejunal junctions with use of barium -
risk for
FLUIDS
constipation
GIVE
- Small bowel follow-through – extension of the upper GI x-ray with use of barium
- Barium enema – X-ray of large intestine with use of barium
- Percutaneous transhepatic cholangiography (PTC) – examines biliary duct system using iodine dye
- Magnetic resonance cholangiopancreatography (MRCP)
Esophagogastroduodenoscopy (EGD)
- Visual exam of the esophagus, stomach, duodenum with use of fiberoptic scope
- Preparation: NPO for 6-8 hours and avoid anticoagulants, aspirin, NSAIDS several days before procedure
- Procedure: Moderate sedation and lasts about 20-30 minutes
- Post procedure:
o Keep patient NPO until gag reflex returns
o Priority care includes preventing aspiration and assess for any bleeding or pain that could
indicate perforation
Endoscopic retrograde cholangiopancreatography (ERCP)
- Visual and radiographic exam of the liver, gallbladder, bile ducts, and pancreas
, - Use radiopaque dye
- Used to diagnose obstruction as well as treat obstructions
- Preparation: NPO for 6-8 hours and typically avoid anticoagulants as determined by provider
- Procedure: Moderate sedation and lasts 30 minutes to 2 hours
- Post procedure:
o Keep patient NPO until gag reflex returns
o Priority care includes preventing aspiration and assess for any bleeding or pain that could
indicate perforation
o Assess for gallbladder inflammation and pancreatitis- severe abdominal pain, nausea and
vomiting, fever, and elevated lipase
Small bowel endoscopy (enteroscopy)
- Provides a visual view of the small intestine
- Used to evaluate and locate source of GI bleeding
- Preparation:
o NPO except water for 8-10 hours then complete NPO for 2 hours before swallowing capsule
-
- Procedure:
o Sensors are placed on abdomen and patient wears a data recorder
o Patient swallows the capsule endoscope and can resume normal activity
o Patient may eat 4 hours after swallowing the capsule
o Procedure lasts 8 hours
- Post procedure:
o Explain to the patient that the capsule endoscope is excreted naturally and will be seen in the
stool
Colonoscopy
- Endoscopic exam of the entire large intestine – can be used to visually diagnose, biopsy and treat
- Baseline test should be done at age 50 and every 10 years
- Preparation:
o Clear liquids the day before
o NPO 4-6 hours prior
o Avoid aspirin, anticoagulants, and antiplatelet drugs for
several days before
o Adequate bowel cleansing is essential – follow provider orders for oral and rectal preparation;
Patient should be passing clear liquid prior to procedure
- Procedure: Moderate sedation and procedure lasts 30-60 minutes
- Post procedure:
o Observe for signs of perforation (severe pain) and hemorrhage
o Feelings of fullness and cramping are expected
o Fluids are permitted after the patient passes flatus to indicate that peristalsis has returned
Stomatitis
Inflammation within the oral cavity
- Painful single or multiple ulcerations that appear as inflammation and erosion of the protective lining of the
mouth; sores cause pain and open areas place the person at risk for bleeding and infection
- Mild erythema (redness) may respond to topical treatments
, - Extensive stomatitis may require treatment with systemic analgesics or medications
Causes:
- Infection – bacteria and viruses have a role in recurrent stomatitis
- Allergies – certain foods, such as coffee, potatoes, cheese, nuts, citrus fruits, and gluten may trigger allergic
responses that cause aphthous ulcers
- Vitamin deficiency – B vitamins, folate, zinc, iron
- Systemic disease and immunosuppression
- Irritants – tobacco and alcohol
Assessment:
- History of recent infections
- Nutritional changes
- Oral hygiene habits or oral trauma
- Stress
- Drug history
- If lesions are seen along the pharynx and the patient reports painful swallowing, the lesions might extend
down the esophagus
Interventions:
- Remove dentures
- Encourage or provide oral hygiene after each meal and as often as needed
- Increase oral care to every 2 hours or more
- Use a soft toothbrush or gauze
- Encourage frequent rinsing of the mouth with warm saline or baking soda solution
- Avoid commercial mouthwashes, specifically ones with alcohol and lemon/glycerin
- Assist with food choices
o Soft, bland, and nonacidic foods can decrease irritation; cool food can be soothing
Drug therapy:
- Antimicrobials for control of infection
o Ex. Tetracycline, Minocycline, chlorhexidine mouthwashes
- Herpes simplex
o IV Acyclovir (Zovirax) if severe or with immunocompromised patient; can be given oral or
topical
- Fungal infections/Yeast
o Nystatin (Mycostatin) swish/swallow
- Pain control
o Anesthetics; ex. Orabase, Anbesol, Campho-Phenique
Oral Cancer
Squamous cell carcinoma -
most common
- Oral lesions appear as red, raised, eroded areas on the lips, tongue, buccal mucosa, and oropharynx
- 90% of oral cancers – major risk factors are increasing age, tobacco use, alcohol use
Basal cell carcinoma
- Oral lesion is asymptomatic and resembles a raised scab – occurs primarily on the lips
- Lesion evolves into a characteristic ulcer with a raised, pearly border
- Major risk factor is excessive sunlight exposure
Kaposi’s Sarcoma
- Malignant lesion in blood vessels – usually painless and appears as a raised, purple nodule or plaque
- Most common site is the hard palate but can be found on the gums, tongue, or tonsils
- Most often associated with AIDS
Clinical Manifestations
- Bleeding from the mouth, poor appetite, difficulty chewing, difficulty swallowing, poor nutritional status and
