This document provides information on assessing patients for gastrointestinal issues. It outlines steps for a physical exam including inspection of the mouth and abdomen. It describes common GI symptoms like pain, indigestion, changes in bowel habits, and blood in the stool. Diagnostic tests are discussed including blood tests, stool tests, imaging studies, and endoscopy. Nursing interventions are described for preparing patients and providing care and education during diagnostic procedures.

1. Gastrointestinal Assessment Physical Exam 1

3. Note the character, duration, pattern, frequency, location, distribution and time of the pain.

4. Aggravating factors – meals, rest, defecation, and vascular disorders may directly affect the pain

5. Indigestion - upper abdominal discomfort or distress associated with eating.

6. Most common symptom of patients with GI dysfunction.

7. Gastric peristaltic movements may or may not relieve the pain

8. Can result form disturbed nervous system control of the GI tract or elsewhere in the body

11. May result to belching or flatulence

12. Complain of bloating, distention or being “full of gas”

13. Excessive flatulence – maybe symptom of gallbladder disease or food intolerance.

14. Nausea and vomiting - Another major symptom of GI disease.

15. Vomiting (emesis) is usually preceded by nausea

16. Can be triggered by odors, activity or food intake.

17. Vomitus may vary in color and content

18. May contain undigested food particles or blood (hematemesis)

19. When vomiting occurs soon after hemorrhage – bright red

20. If blood has been retained in the stomach – coffee-ground appearance because of digestive enzymes

23. Normally light to dark brown

26. Melena – black tarry stool is produced if blood is shed into the upper GI tract.

27. Blood entering the lower portion of the GIT or passing rapidly through it will appear bright or dark red.

29. Bulky, greasy, foamy stools foul in odor, gray with a silvery sheen.

30. Light gray or clay-colored stool-caused by absence of urobilin

31. Stool with mucus threads or pus

32. Small, dry, rock-hard mass called scybala, streaked with blood from rectal trauma

34. sequence Inspection Auscultation Percussion Palpation 11

36. Ulcers, nodules, swellling, discoloration and inflammation are noted

38. PHYSICAL ASSESSMENT 2. Abdomen a. Inspection - note for skin changes and scars from previous surgery, contour and symmetry, localized bulging, distention or peristaltic waves. b. Auscultation - notes the character, location and frequency of bowel sounds. - Assess bowel sounds in all four quadrants using the diaphragm of the stethoscope (high pitched and gurgling sounds) - Bowel sounds (Borborygmi sound) NORMAL – Sounds heard every 5-20 seconds HYPOACTIVE – 1-2 sounds in 2 minutes HYPERACTIVE – 5-6 sounds heard in less than 30 seconds ABSENT – no sound in 3-5 minutes

40. PHYSICAL ASSESSMENT c. Palpation > Light palpation may identify areas of tenderness or swelling > Deep palpation may identify masses in any four quadrants. > Identify direct and rebound tenderness…HOW? > Identify findings in relation to surface landmarks (xiphoid process, costal margins, ASIS, symphysis pubis) and four quadrants (RUQ,RLQ,LUQ,LLQ) d. Percussion - Note for tympany or dullness

41. PHYSICAL ASSESSMENT 3. Anus and Perineal Area > Inspect and palpate areas of excoriation or rash, fissures or fistula openings or external hemorrhoids > Digital rectal examination may note areas of tenderness or mass.

42. DIAGNOSTIC ASSESSMENT Blood Tests Stool Tests Breath Tests Abdominal Ultrasonography DNA Testing Imaging Studies Computed Tomography (CT) Scan Magnetic Resonance Imaging (MRI) Scintigraphy Endoscopic Procedures Manometry and Electrophysiologic Studies Gastric Analysis, Gastric Acid Stimulation Test and pH Monitoring Laparoscopy (Peritoneoscopy)

43. GENERAL NURSING INTERVENTIONS FOR PATIENTS HAVING GI DIAGNOSTIC ASSESSMENT Provide general information about a healthy diet and nutritional factors that can cause GI disturbances Providing information about the test and the activities required of the patient Alleviating anxiety Help patient cope with discomfort Encourage family members to offer emotional support to patient during the test Assess for adequate hydration before, during and immediately after the procedure and provide education about maintenance of hydration

46. Quantitative 24-72-hour collections must be kept refrigerated until taken to the laboratory

48. Rare meat, liver, poultry, turnips, broccoli, cauliflower, melons, salmon, sardines or horseradish within 7 days before testing

49. Medications: aspirin, ibuprofen, indomethacin, colchicine, corticosteroids, cancer chemotherapeutic agents and anticoagulants

51. Hematest II SENSA

53. Hemoporphyrin assays detect the broadest range of blood derivatives

55. Determines the amount of hydrogen expelled in the breath after it has been produced in the colon and absorbed into the blood.

57. Used to indicate the size and configuration of abdominal structures.

58. Useful in detection of cholelithiasis, cholecystitis, and appendicitis and acute colonic diverticulitis.

59. Advantages: No ionizing radiation, no noticeable side effects, relatively inexpensive.

60. Disadvantage: It cannot be used to examine structures that lie behind bony tissue….

61. Endoscopic ultrasonography – gives direct imaging of a target area.

62. Nursing Interventions:

63. Patients fasts for 8-12 hours before the test

64. If gallbladder studies is to be done, patient should be fat-free the evening before the test

67. NPO after midnight before the test.

68. Physician may prescribe laxative

69. Discourage smoking on the morning before the examination

70. Withholds all medications

72. Barium is instilled rectally to visualize the lower GI tract.

73. To detect presence of polyps, tumors and other lesions of small intestine and demonstrate abnormal anatomy or malfunction of the bowel.

74. Takes about 15-30 minutes

77. Low residue diet 1-2 days before the test

78. Clear liquid diet and laxative the evening before

79. NPO after midnight

80. Cleansing enemas until returns are clear the following morning

81. Barium enemas should be scheduled before any upper GI studies.

82. Contraindications: Signs of perforations or obstruction, GI bleeding prohibit the use of laxatives and enemas

84. Physician may prescribe an IV or oral contrast agent. Dye allergy history should be asked.

86. Useful in evaluating abdominal soft tissues as well as blood vessels, abscesses, fistulas, neoplasms, and other sources of bleeding.

87. Contraindications: patients with permanent pacemakers, artificial heart valves and defibrillators, implanted insulin pumps or implanted transcutaneous electrical nerve stimulation devices, with internal metal devices (aneurysm clips) or intraocular metallic fragments.

88. Nursing Interventions:

89. Patient should not eat or drink for 6-8 hours before the test.

90. Remove all jewelry and other metals

92. Scintigraphic scanning measure the uptake of tagged red blood cells and leukocytes which will define areas of inflammation, abscess, blood loss.

93. A sample of blood is removed, mixed with a radioactive substance and reinjected into the patient.

95. After meal, patient is positioned under a scintiscanner and measures the passage of radioactive substance out of the stomach.

96. For evaluation of diabetic gastroparesis and dumping syndrome, chronic constipation and obstructive defecation syndrome

97. Abdominal x-rays are taken every 24 hours until all markers are passed

98. The process takes 4-5 days but in severe constipation may take as long as 10 days.

100. Gastroscopy

101. ENDOSCOPIC PROCEDURESEGD After the patient is sedated, the endoscope is lubricated with a water-soluble lubricant and passed smoothly and slowly along the back of the mouth and down into the esophagus. Biopsy forceps to obtain tissue specimens or cytology brushes to obtain cells for microscopic study can be passed through the scope. Patients may experience nausea, choking or gagging.

102. ENDOSCOPIC PROCEDURESEGD Use of oral anesthetics and moderate sedation makes it important to monitor and maintain the oral airway during the after the procedure. Monitor oxygen saturation by means of pulse oximeters, and supplemental oxygen may be administered if necessary

103. ENDOSCOPIC PROCEDURESEGD: Nursing Interventions The patient should not eat or drink for 6 to 12 hours before the examination. Help the patient spray or gargle with a local anesthetic. Administer a sedative such as midazolam intravenously just before the scope is introduced. The nurse may also administer atropine to decrease secretion, and glucagon to relax smooth muscle.

104. ENDOSCOPIC PROCEDURESEGD: Nursing Interventions Position the patient on the left side to facilitate saliva drainage and provide easy access for the endoscope. Instruct the patient not to eat or drink until the gag reflex returns. Place the patient in the Simms position until he or she is awake, and then place the patient in the semi-Fowler’s position until ready for discharge

105. ENDOSCOPIC PROCEDURESEGD: Nursing Interventions After gastroscopy, observe for signs of perforation: bleeding, unusual dysphagia, fever. Monitor the pulse and blood pressure for changes that can occur with sedation. Test the gag reflex. Relieve minor throat discomfort by giving lozenges, saline gargle and oral analgesics

106. Colonoscopy

107. Fiberoptic Colonoscopy Direct visual inspection of the colon to the cecum. Used commonly as a diagnostic and screening device. Tissue biopsies can be obtained as needed, and polyps can be removed and evaluated. May also be used to evaluate diarrhea of unknown cause, occult bleeding, or anemia

108. Fiberoptic Colonoscopy Usually performed while the patient is lying on the left side with the legs drawn up toward the chest. Discomfort may result from instillation of air to expand the colon or from insertion and moving of the scope. Potential complications include cardiac dysrhythmias and respiratory depression resulting from the medications administered, vasovagal reactions and circulatory overload or hypotension as a result of under- or over hydration.

109. Fiberoptic Colonoscopy Adequate colon cleansing provides optimal visualization and decreases the time needed for the procedure. Patient should limit the intake of liquids for 24 to 72 hours before the examination. Prescribe laxatives for two nights before the examination and a Fleet’s or saline enema until the return runs clear on the morning of the test. Clear liquid diet starting at noon the day before the procedure.

110. Fiberoptic Colonoscopy Patient ingests lavage solutions orally at intervals over 3 to 4 hours. Cardiopulmonary clearance prior to test for patients with known or suspected cardiac and pulmonary conditions, and in patients over the age of 40 years. NSAIDs, aspirin, ticlopidine and pentoxifylline must be discontinued before the test and for 2 weeks after the procedure. Informed consent must be obtained.

111. Fiberoptic Colonoscopy NPO after midnight before the test. Monitor for changes in oxygen saturation, vital signs, color and temperature of the skin, level of consciousness, abdominal distention, vagal response and pain intensity during the test. After the procedure, patients who were sedated are maintained on bed rest until fully alert. Abdominal cramps are common as a result of increased peristalsis stimulated by air insufflated into the bowel during the procedure

112. Fiberoptic Colonoscopy Immediately after the procedure, observe the patient for signs and symptoms of bowel perforation. If midazolam was used, the nurse should explain its amnesic effect; it is important to provide written instructions, because the patient may be unable to recall verbal information. Instruct the patient to report any bleeding to the physician.

113. Flexible Fiberoptic Sigmoidoscopy

114. Anoscopy, Proctoscopy and Sigmoidoscopy Visualize the lower portion of the colon to evaluate rectal bleeding, acute or chronic diarrhea, or change in bowel patterns, and to observe for ulceration, fissures, abscesses, tumors, polyps, or other pathologic processes. Rigid or flexible fiberoptic scopes can be used. Anoscopes are rigid scopes that are used to examine the anus and lower rectum. Proctoscopes and sigmoidoscopes are rigid scopes used to inspect the rectum and sigmoid colon.

115. Anoscopy, Proctoscopy and Sigmoidoscopy For rigid scopes, the patient assumes the knee-chest position at the edge of the bed or examining table. Keep the patient informed about the progress of the examination and to explain that the pressure exerted by the instrument will create the urge to have bowel movement.

116. Anoscopy, Proctoscopy and Sigmoidoscopy For flexible scope procedures, the patient assumes a comfortable position on the left side, with the right leg bent and placed amteriorly. It is important to keep the patient informed throughout the examination and to explain the sensations associated with the examination. These examinations require only limited bowel preparation, including a warm tap water or Fleet’s enema until returns are clear.

117. Anoscopy, Proctoscopy and Sigmoidoscopy Dietary restrictions usually are not necessary, and sedation usually is not required. Monitor the vital signs, skin color and temperature, pain tolerance and vagal response during the procedure. After the procedure, the nurse monitors the patient for rectal bleeding and signs of intestinal perforation. On completion of the examination, the patient can resume regular activities and dietary practices.

118. DIAGNOSTIC ASSESSMENT Manometry and Electrophysiologic Studies. Gastric Analysis, Gastric Acid Stimulation Test and pH Monitoring Laparoscopy (Peritoneoscopy)

119. Gastrointestinal Assessment Laboratory Procedures 54

120. 55 Foods and Medications Color Altering Substance Dark brown Meat protein Green Spinach Red Carrots and beets Dark red or brown Cocoa Yellow Senna Black Bismuth, iron, licorice and charcoal Milky white Barium Health History and Clinical Manifestations

121. COMMON LABORATORY PROCEDURES FECALYSIS Examination of stool consistency, color and the presence of occult blood. Special tests for fat, nitrogen, parasites, ova, pathogens and others 56

122. COMMON LABORATORY PROCEDURES FECALYSIS: Occult Blood Testing Instruct the patient to adhere to a 3-day meatless diet No intake of NSAIDS, aspirin and anti-coagulant Screening test for colonic cancer 57

123. COMMON LABORATORY PROCEDURES Upper GIT study: barium swallow Examines the upper GI tract Barium sulfate is usually used as contrast 58

124. COMMON LABORATORY PROCEDURES Upper GIT study: barium swallow Pre-test: NPO post-midnight Post-test: increase pt fluid intake, instruct that stools will turn white, monitor for obstruction, laxative is also ordered 59

125. 60

126. 61

127. COMMON LABORATORY PROCEDURES Lower GIT study: barium enema Examines the lower GI tract Pre-test: Clear liquid diet and laxatives, NPO post-midnight, cleansing enema prior to the test 62

128. COMMON LABORATORY PROCEDURES Lower GIT study: barium enema Post-test: Laxative is ordered, increase patient fluid intake, instruct that stools will turn white, monitor for obstruction 63

129. 9/19/2011 64

130. COMMON LABORATORY PROCEDURES Gastric analysis Aspiration of gastric juice to measure pH, appearance, volume and contents Pre-test: NPO 8 hours, avoidance of stimulants, drugs and smoking Post-test: resume normal activities 65

131. COMMON LABORATORY PROCEDURES EGD (esophagogastroduodenoscopy) Visualization of the upper GIT by endoscope Pre-test: ensure consent, NPO 8 hours, pre-medications like atropine and anxiolytics 66

132. 67

133. COMMON LABORATORY PROCEDURES EGD esophagogastroduodenoscopy Intra-test: position : LEFT lateral to facilitate salivary drainage and easy access 68

134. COMMON LABORATORY PROCEDURES EGD (esophagogastroduodenoscopy) Post-test: NPO until gag reflex returns, place patient in SIMS position until he awakens, monitor for complications, saline gargles for mild oral discomfort 69

135. COMMON LABORATORY PROCEDURES Lower GI- scopy Use of endoscope to visualize the anus, rectum, sigmoid and colon Pre-test: consent, NPO 8 hours, cleansing enema until return is clear 70

136. 71

137. COMMON LABORATORY PROCEDURES Lower GI- scopy Intra-test: position is LEFT lateral, right leg is bent and placed anteriorly Post-test: bed rest, monitor for complications like bleeding and perforation 72

138. 9/19/2011 73

139. COMMON LABORATORY PROCEDURES Cholecystography Examination of the gallbladder to detect stones, its ability to concentrate, store and release the bile Pre-test: ensure consent, ask allergies to iodine, seafood and dyes; contrast medium is administered the night prior, NPO after contrast administration 9/19/2011 74

140. COMMON LABORATORY PROCEDURES Cholecystography Post-test: Advise that dysuria is common as the dye is excreted in the urine, resume normal activities 75

141. COMMON LABORATORY PROCEDURES Paracentesis Removal of peritoneal fluid for analysis 76

142. COMMON LABORATORY PROCEDURES Paracentesis Pre-test: ensure consent, instruct to VOID and empty bladder, measure abdominal girth 77

143. COMMON LABORATORY PROCEDURES Paracentesis Intra-test:Upright on the edge of the bed, back supported and feet resting on a foot stool 78

144. DIAGNOSTIC EVALUATION: Computed Tomography Provides cross-sectional images of abdominal organs and structures. The patient should not eat or drink for 8 hours before the test. The practitioner may prescribe an intravenous or oral contrast agent. Obtain a history and ask about allergies. Should be performed before barium studies. 79

145. DIAGNOSTIC EVALUATION: Computed Tomography 80

146. DIAGNOSTIC EVALUATION: MRI Used in gastroenterology to supplement ultrasonography and CT scanning. Noninvasive technique that uses magnetic fields and radio waves to produce an image of the area being studied. Physiologic artifacts of heartbeat, respiration and peristalsis may create a less-than-clear image. 81

147. DIAGNOSTIC EVALUATION: MRI The patient should not eat or drink for 8 hours before the test. The patient must remove all jewelry and other metals. Warn patients that the close-fitting scanners used in many MRI facilities may induce feelings of claustrophobia and that the machine will make a knocking sound during the procedure. 82

148. DIAGNOSTIC EVALUATION: MRI 83

149. COMMON LABORATORY PROCEDURES Liver biopsy Pretest Consent NPO Check for the bleeding parameters 84

150. COMMON LABORATORY PROCEDURES Liver biopsy Intratest Position: Semi fowler’s LEFT lateral to expose right side of abdomen 85

151. COMMON LABORATORY PROCEDURES Liver biopsy Post-test: position on RIGHT lateral with pillow underneath, monitor VS and complications like bleeding, perforation. Instruct to avoid lifting objects for 1 week 86

152. The NURSING PROCESS in GIT Disorders Assessment Health history Nursing History PE Laboratory procedures 87

153. GASTRIC GAVAGE: Nursing Intervention Gastric gavage is the introduction of liquid feedings directly into the stomach. Purpose: Effective in persons who have difficulty in swallowing, prolonged unconsciousness, or anorexia. Useful when there is oral or esophageal obstruction or trauma. Life-saving in one who is debilitated or who has had surgery on some part of the GIT that does not permit normal ingestion of food.

154. GASTRIC GAVAGE: Nursing Intervention Avenues: Nasogastric/orogastric Esophagotomy – a stoma (temporary or permanent) may be created at one of several sites along the esophagus. Gastrostomy Jejunostomy

155. GASTRIC GAVAGE: Nursing Intervention Feeding Methods: Gravity Drip-regulated (a Murphy drip is connected by tubing to a receptacle or Kelly flask) which hangs on an IV pole. Motor pump

156. GASTRIC GAVAGE: Nursing Intervention Continuous Nursing Assessment Recognize that even though nutritional deficits are corrected, some other problems may arise. Cleanse all containers and tubings thoroughly. Aspirate the tubing prior to feeding to verify that the tube is inside the patient’s stomach. Avoid air bubbles in the system. Provide oral and nasal hygiene before and after orogastric and nasogastric feedings for comfort or prevent infection.

157. GASTRIC GAVAGE: Nursing Intervention Continuous Nursing Assessment Follow each feeding with water to flush tubing for cleansing and to promote fluid balance. Monitor patient for signs of fluid and electrolyte imbalance. Record amount of feeding and water; indicate patient’s participation and acceptance.

158. GASTRIC GAVAGE: Nursing Intervention Patient Education Since tube should be changed every 2 to 3 days, the patient may be taught how to do it. The patient should learn how to feed himself. Skin requires special care.

161. Method of supplying nutrients to the body via IV route

163. Solution: 25% glucose and synthetic amino acids

165. Air embolism

166. Clotted line

167. Displacement

168. Sepsis

169. Hyperglycemia

170. Fluid overload

172. Weigh daily

173. Prevent infection

174. Change dressings aseptically twice a week

176. Inability to take food by mouth

177. Excessive nutritional needs that cannot be met by the usual methods

179. CXR immediately after subclavian line insertion

180. Assess weight, baseline electrolytes, blood glucose, zinc and copper levels before treatment begins

181. Maintain aseptic technique during dressing changes

182. Maintain infusion rate

183. Monitor for complications - Infection - Pneumothorax during insertion - Hypoglycemia - Zinc deficiency - Hyperglycemia - Fluid overload - Air embolism - Hyperglycemic, hyperosmolar nonketotic coma

185. Located on the right hand side of the tummy.

186. Colostomy stoma

187. Note how it is flusher with the skin

189. Colostomy Care Assess every shift for 3 days post op Normal stoma: pink Abnormal: cyanotic; dusky color, black/brown Initially it protrudes 1 inch outward Check bowel sounds q 4 Begins functioning after 48 hrs Avoid gasforming foods/ high fiber

190. Colostomy Care Stoma irrigations: 500-1000ml of warm or tepid water Nsg. Alert :Prior to 1st irrigation, insert gloved finger to note direction of stoma Hang bag 12-14 inches above the stoma Lubricate and insert 3-4 inches Infuse for 15 mins Expect return after 15-20 mins

191. The ABDOMINAL examination The sequence to follow is: Inspection Auscultation Percussion Palpation 103

192. Most Common GIT Symptom Abdominal Pain Major symptom of GI disease. Character Duration Pattern Frequency Location Distribution of referred pain Time of the pain Is it? Medical Abdomen? Surgical Abdomen? When to refer? 104

193. Indigestion Upper abdominal discomfort or distress associated with eating. Most common symptom of patients with GI dysfunction. Fatty foods tend to cause the most discomfort. Coarse vegetables and highly seasoned foods can also cause considerable distress. 105

194. Intestinal Gas The accumulation of gas in the GIT may result in belching or flatulence. Patients often complain of bloating, distention, or “being full of gas.” 106

195. Nausea and Vomiting Vomiting is usually preceded by nausea, which can be triggered by odors, activity, or food intake. Emesis, or vomitus, may vary in color and content. Hematemesis refers to bloody vomitus. 107

196. Change in Bowel Habits and Stool Characteristics These may signal colon disease. Diarrhea (abnormal increase in the frequency and liquidity of the stool or in daily stool weight or volume) occurs when the contents move so rapidly through the intestine and colon. Constipation (decrease in the frequency of stool, or stools that are hard, dry, and of smaller volume than normal) may be associated with anal discomfort and rectal bleeding. 108

197. Change in Bowel Habits and Stool Characteristics Stool is normally light to dark brown. Ingestion of certain foods and medications, as well as the presence of blood, can change the appearance of stool. Bulky, greasy, foamy stools that are foul in odor; stool color is gray with a silvery sheen (fat malabsorption). Light gray or clay-colored stool (absence of urobilin). Mucus threads or pus in stools (infection). 109

198. Change in Bowel Habits and Stool Characteristics Scybala (small, dry, rock-hard masses) often seen in narrowing of the colonic lumen. Loose, watery stool that may or may not be streaked with blood (inflammatory conditions). 110

199. PHYSICAL ASSESSMENT Assessment of the mouth, abdomen and rectum. Mouth, tongue, buccal mucosa, teeth and gums are inspected, and ulcers, nodules, swelling, discoloration, and inflammation are noted. Patients with dentures should remove them during this part of the examination to allow good visualization. 111

200. PHYSICAL ASSESSMENT: The Abdomen Patient lies supine with knees flexed slightly for inspection, auscultation, palpation and percussion. The nurse performs inspection first, noting skin changes and scars from previous surgery. It is also important to note the contour and symmetry of the abdomen, to identify any localized bulging, distention, or peristaltic waves. 112

201. Abdominal Assessment: Auscultation Character, location and frequency of bowel sounds. Assess bowel sounds in all four quadrants using the diaphragm of the stethoscope. Categorize and document frequency of bowel sounds into normal (5 to 6/min), hypoactive (1 sound/min), hyperactive (5 to 6 sounds in less than 30 seconds), or absent (no sound in 3 to 5 minutes). 113

202. Abdominal Assessment: Percussion and Palpation Tympany or dullness. Light palpation for identifying areas of tenderness or swelling. Deep palpation to identify masses in all four quadrants. If any area of discomfort is identified, the nurse can assess for rebound tenderness. 114