Chapter 5 – Gastrointestinal System
Health promotion and disease prevention are important components of any assessment, including a GI system assessment. Consider all available subjective and objective data when determining appropriate interventions. As part of subjective data collection, ask the client about risk factors, social determinants, and other considerations.
The inquiry part is integrated throughout the assessment. Many of the probing questions may be asked when doing the subjective assessment. However, some of the questions will be formulated based on your critical reflection of data collected during the subjective and objective assessment. It is this data that will inform your clinical judgment and the health promotion needed for a specific client.
Hand hygiene is necessary to maintain a healthy GI system and prevent unhealthy microorganisms from entering the body. Hand hygiene can decrease the risk of various mouth and other GI-related viruses, such as herpes simplex virus type 1 (e.g., cold sores, fever blisters) and viral gastroenteritis (e.g., stomach flu), parasites on the surfaces of soil, food, and water (e.g., giardia), and bacteria found in the mouth that cause decay (e.g., Streptococcus mutans) or in contaminated food that can cause diarrhea and stomach cramps/pain (e.g., Salmonella).
Probing questions related to hand hygiene include:
- Tell me about when you wash your hands?
- How often do you wash your hands?
- What is involved in washing your hands? (Further probes might include: What are the steps involved? How long do you do it for?)
You may need to educate the client about effective hand hygiene practices such as when to perform it and how to do it. This education should be dependent on the client’s age. For example, you could teach a child to wash their hands along with their favorite song or a fun educational video; with older adults, you could introduce various assistive devices (e.g., nail brush) for clients with limited fine dexterity. Teach clients to perform hand hygiene frequently in healthcare and in work settings, as well as when they arrive at and leave a building, come home, before meal preparation, before and after meals, and before and after using the washroom.
Hand hygiene generally refers to either hand washing with soap and water or hand sanitizing with an alcohol-based hand rub. The mechanical actions of rubbing and creating friction helps to break down and remove various microorganisms from hands, preventing them from entering the mouth and the rest of the GI tract. Clients may require education about specific techniques.
Hand washing technique:
- Rinse hands with warm water, lather with soap for 20 seconds.
- Rinse hands with water.
- Dry hands with a paper towel.
- Turn off the tap with your elbow or the paper towel.
NOTE: Consider how to make it fun with children, for example by singing a song that lasts 20 seconds.
Hand sanitizing technique with alcohol-based hand rub:
- Ensure hands have no soil on them and are visibly clean.
- If there is visible soil, perform hand washing instead.
- Dispense a sufficient amount of gel in hand.
- Rub hands together so that all areas of the hands are covered.
- Rub hands together for about 15 seconds until they are dry.
- If hands dry before 15 seconds, use more hand gel.
Mouth Care and Dental Care
Mouth and dental care is an important part of maintaining the health of the oral cavity of the GI system, particularly the teeth and gums.
Probing questions related to mouth care and dental care include:
- Tell me about any personal mouth and dental care you perform. Probing questions could include:
- How often do you brush your teeth?
- How often do you floss?
- Can you tell me about your brushing technique (e.g., brushing away from gums, type of toothbrush)?
- When was the last time you saw a dentist for a check-up or a hygienist for a dental cleaning? How often do you typically have your teeth cleaned?
- Do you have any concerns about your mouth and dental care?
Begin by addressing any of the client’s concerns about their mouth and dental care. Remember to consider relational and structural approaches to health promotion. For example, children learn how to brush their teeth and maintain a schedule based on support from their parent/caregiver. Thus, it is important that you assess social and familial support related to dental care. Based on your assessment and the client’s needs, you may need to provide health promotion education about mouth and dental care.
The Canadian Dental Association (2021) recommends brushing teeth at least twice a day, flossing once a day, and having a cleaning about every six months. However, there are many inequities associated with dental care, for example geographical access to a dentist when living in rural, remote, and Northern communities. Some communities lack access to clean water, and some water systems are not fluoridated. Almost 30% of the water systems in Ontario are not fluoridated, and this has a significant effect on dental decay. The lack of fluoridated water systems has been identified as a problem for many Indigenous communities (Public Health Agency of Canada, 2017).
Another consideration is the financial costs associated with dental cleanings and dentist appointments. These are not always covered under provincial and territorial health insurance plans in Canada. Ask the client if they are covered under a private insurance plan related to their work or under a family member’s plan or through their post-secondary educational institution. Ontario has a dental care program for children under the age of 17 from low-income families (https://www.ontario.ca/page/get-dental-care) and low-income seniors (65 and older; http://www.cda-adc.ca/en/oral_health/cfyt/dental_care_seniors/flossing_brushing.asp). Some dental schools also provide dental care at minimal cost.
Diet affects the functioning of the GI system. A healthy diet helps maintain the health of the GI system, fuels the body to function, and maintains an ideal body mass index; a diet high in fibre with adequate hydration helps keep the intestines moving and bowel movements regular. In contrast, an unhealthy diet can lead to malnutrition, obesity, dental decay, altered bowel patterns such as constipation and diarrhea, and can affect other body systems and lead to various health problems such as diabetes, some cancers, cirrhosis, and heart disease.
Check out this video about how the food you eat affects your gut. It was created by Dr. Shilpa Ravella, a gastroenterologist.
Probing questions related to diet could include:
- Tell me about your usual diet?
- What have you eaten in the last 24 hours? Is that your usual diet?
- Do you have any food allergies or intolerances? (Further probes could include: What type of allergies? What is the reaction? (e.g., anaphylaxis, rash) When did the allergy start? How do you treat it?)
- Do you have enough money to buy healthy food?
- Tell me about your cultural practices related to diet?
You could assess the client’s familiarity with Health Canada’s Food Guide (Government of Canada, 2021) and discuss how they might draw upon it to guide their food choices: https://food-guide.canada.ca/en/. Remember that the food guide still includes Eurocentric elements, so you should collaborate with the client about its relevance in the context of their cultural food practices. A snapshot of the food guide is now offered in dozens of languages: https://www.canada.ca/en/health-canada/services/canada-food-guide/resources/snapshot/languages.html and many resources have been developed for Indigenous populations:
Informed by Canada’s Food Guide, some key elements to discuss with a client when promoting a healthy diet include:
- Eating patterns and cultural practices.
- Making water the drink of choice.
- Making time to enjoy the meal, eating mindfully, allowing the food to digest.
- How to incorporate fibre, probiotics, fermented foods (e.g., kimchi), polyphenols (e.g., almonds), and a variety of food options to promote gut healthy nutrients.
Assess each client’s lifestyle to understand how it affects their diet and how you can help them adapt to include healthier food choices when possible. Use the relational health promotion approach to learn what food and diet means to the client and how their environment and the people within it can influence their choices. For example, young adults attending college or university may have limited access to healthy food choices due to a prevalence of fast food vendors at their institution. In this sort of situation, when a client lacks access to healthy food resources, nurses can source out and advocate for access to food resources within the client’s community (e.g., food banks, breakfast programs), help the client find accessible food services (e.g., student nutrition program), or help the client find resources for grocery delivery. Nurses need to advocate to ensure the particular needs of each client are being met, using the available socioeconomic and environmental resources. By working in partnership with each client, you can create effective interventions that support the client in achieving a healthy diet.
Smoking, Alcohol, and Cannabis
Smoking or chewing tobacco has negative effects due to the risk of cancer in the mouth, tongue, esophageal, stomach, pancreas, and liver. Alcohol and cannabis can have positive and negative effects on the GI system.
For example, red wine contains polyphenols from the skins of the red grapes. Polyphenols are plant-based compounds that are healthy for intestinal bacteria; evidence suggests that polyphenols have a probiotic effect on intestinal bacteria (Moorthy et al., 2020). However, this is not a good reason to start drinking wine, because many plant-based foods such as fruits contain polyphenols. Moreover, alcohol can have negative effects on your GI tract: it can cause diarrhea in some due to increased acid production in the intestines, and constipation in others due to its diuretic effect. Some people are also intolerant to the additives in alcohol (e.g., gluten in beer). The liver is the main organ that processes alcohol, and heavy drinking over a long period can damage the liver and lead to cirrhosis. Additionally, because the liver processes many medications, a damaged liver can affect how medications are absorbed and their effects. The most recent Canadian guidelines now suggest that there are health risks associated with any level of alcohol consumption, although negligible with two drinks or less weekly (Paradis et al., 2022). From a GI perspective, alcohol is a carcinogen that is linked to colon cancer as well as rectum, mouth, liver, and esophageal cancer (Paradis et al., 2022). Overall, the key is to consume limited amounts of alcohol.
The Canadian Society of Intestinal Research has reported that cannabis can be used effectively to treat loss of appetite and nausea and vomiting related to GI conditions such as irritable bowel diseases (IBD) and multiple sclerosis (MS) (https://badgut.org/information-centre/a-z-digestive-topics/cannabis/). However, negative GI-related effects of consuming cannabis have also been reported: some individuals are allergic, and long-term use can cause cannabinoid hyperemesis syndrome, which causes nausea, vomiting, and abdominal pain. Overall, clients should discuss cannabis use with their primary healthcare provider prior to consuming.
Probing questions related to alcohol, cannabis, and smoking could include:
- Tell me about how much alcohol you consume in a day? If the client does not consume alcohol daily, you can assess consumption based on weekly, monthly, or none. If the client’s answer is affirmative, ask probing questions such as: How much (e.g., ounces a day)? What type of alcohol (e.g., red wine, beer)? For how long? Can you tell me the reasons?
- Do you smoke or ingest cannabis? If affirmative, ask similar probing questions as above. Also ask if it is medically prescribed or recreational.
- Do you smoke cigarettes or use any tobacco-related products? If affirmative, ask similar probing questions as above examples. Also ask if the client inhales or chews tobacco.
- If you do not currently consume alcohol/cannabis/smoking, have you ever? If affirmative, you can ask similar probing questions as above, including the reason that the client quit.
- Have you had an allergic reaction to alcohol or cannabis? If affirmative, ask probing questions such as: What is the reaction (e.g., anaphylaxis, irritable bowel)? When did it start? How do you treat it?
Health promotion education should focus on each client’s lifestyle and reasons for consuming alcohol, cannabis, or tobacco. Interventions related to using safely or quitting the consumption should be tailored to each client and could include counselling, cognitive-behavioural therapy, and support groups. You should also consider the relational promotion approach: for example, a client’s consumption can be influenced by their surrounding environment (e.g., family, friends, workplace).
If the client is interested in using medical cannabis, your role as a nurse is to understand their interest and help them find appropriate resources specific to their needs. You can also advocate for educational resources about medical cannabis if a client’s healthcare setting or community lacks resources or support.
Activity and exercise promote peristalsis of the intestines ensuring that content moves along the digestive tract and helps to maintain a healthy body mass index. It is important for individuals to eat healthy and drink an adequate amount of fluids (primarily water) based on their age, genetics, and activity level. Guidelines vary, but it is suggested that individuals participate in about 30 to 60 minutes of aerobic activity five to seven times per week.
Check out this video about improving digestion with movement. It was created by Dr. Jaclyn Tolentino, a family medicine physician.
Probing questions related to activity could include:
- Tell me about your activity or exercise routine?
- What is your exercise routine? What type of exercise? How long do you do this type of exercise for? How many days of the week do you participate in exercise? If the client engages in sports, ask about protective equipment.
- Do you have any mobility limitations?
- Do you have any concerns about your level of activity or exercise?
- Do you have any goals you would like to achieve related to your activity or exercise level?
Assess and collaborate with each client to create an activity/exercise care plan that is based on their goals and needs. The care plan should be realistic and attainable for the client according to their physical capabilities, environment, and availability. You can also assess the client’s access to support systems for additional support, such as community walking groups, fitness apps, and local gym memberships. The participACTION website is a helpful resource: https://www.participaction.com/en-ca.
Remember to assess the client’s broader community structures. For example, does the client’s community have accessible, safe sidewalks or streetlights. This kind of structural approach to health promotion can help address potential inequities. Access to services can vary and can be a barrier to the client’s exercise/activity goals. Other barriers might include finances (e.g., gym memberships, sports registration fees) or geographical location (e.g., different resources available in urban, rural or remote regions). As a nurse, you will need to tailor activity programming to each client. You can also advocate for structures to address inequities.
Canadian Dental Association (2021). Flossing and brushing. http://www.cda-adc.ca/en/oral_health/cfyt/dental_care_seniors/flossing_brushing.asp
Paradis, C., Butt, P., Shield, K., Poole, N., Wells, S., Naimi, T., Sherk, A., & the Low-Risk Alcohol Drinking Guidelines Scientific Expert Panels. (2022). Update of Canada’s Low-Risk Alcohol Drinking Guidelines: Final Report for Public Consultation. Ottawa, Ont.: Canadian Centre on Substance Use and Addiction.
Public Health Agency of Canada (2017). The state of community water fluoridation across Canada. https://www.canada.ca/en/services/health/publications/healthy-living/community-water-fluoridation-across-canada-2017.html