GIT

Gastrointestinal AssessmentPhysical Exam1

Health History and Clinical Manifestations1. Complete history focusing on GI dysfunction.Pain - major symptom of GI disease

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

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

Indigestion - upper abdominal discomfort or distress associated with eating.

Most common symptom of patients with GI dysfunction.

Gastric peristaltic movements may or may not relieve the pain

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

Fatty foods tend to cause discomfort as well as coarse vegetable and highly seasoned foods.

Health History and Clinical ManifestationsIntestinal gas – accumulation of gas in the GI tract.

May result to belching or flatulence

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

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

Nausea and vomiting - Another major symptom of GI disease.

Vomiting (emesis) is usually preceded by nausea

Can be triggered by odors, activity or food intake.

Vomitus may vary in color and content

May contain undigested food particles or blood (hematemesis)

When vomiting occurs soon after hemorrhage – bright red

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

Hematemesis – Vomiting of bloodHealth History and Clinical ManifestationsChanges in bowel habits – a signal of colon diseaseDiarrhea – abnormal increase in frequency and liquidity of the stool or daily stool weight or volume.Occurs when contents move so rapidly through the intestine and colon with inadequate time for absorption of GI contents.

Sometimes associated with abdominal pain or cramping and nausea and vomitingHealth History and Clinical ManifestationsConstipation – decrease in the frequency of stool or stools that are hard, dry and smaller volume than normal.- May be associated with anal discomfort and rectal bleedingStool characteristics

Indigestion of certain foods and medications can change the appearance of stool.Foods and Medications That Alter Stool ColorCOLORDark brownGreenRedDark red or brownYellowBlackMilky whiteALTERING SUBSTANCESMeat proteinSpinachCarrots and beetsCocoaSennaBismuth,iron,licorice & charcoalBarium

Health History and Clinical ManifestationsBlood in the stool

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

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

Lower rectal or anal bleeding if there is streaking of blood on the surface of the stool or noted on toilet tissueHealth History and Clinical ManifestationsOther Common abnormalities in stool characteristics

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

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

Stool with mucus threads or pus

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

Loose, watery stool that may or may not be streaked with blood.Health History and Clinical ManifestationsPrevious GI diseasePast and current medication usePrevious treatment or surgeryDietary historyUse of tobacco and alcohol – type and amountChanges in appetite or eating patternsUnexplained weight gain or loss over the past yearPsychosocial factors – Stress and anxietySpiritual factors -ReligionCultural factors – Beliefs and Tradition

sequenceInspectionAuscultationPercussionPalpation 11

PHYSICAL ASSESSMENTMouthInspection of the mouth, tongue, buccal mucosa, teeth and gums

Ulcers, nodules, swellling, discoloration and inflammation are noted

PHYSICAL ASSESSMENT2. 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

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

PHYSICAL ASSESSMENT3. 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.

DIAGNOSTIC ASSESSMENTBlood TestsStool TestsBreath TestsAbdominal UltrasonographyDNA TestingImaging StudiesComputed Tomography (CT) ScanMagnetic Resonance Imaging (MRI)ScintigraphyEndoscopic ProceduresManometry and Electrophysiologic StudiesGastric Analysis, Gastric Acid Stimulation Test and pH MonitoringLaparoscopy (Peritoneoscopy)

GENERAL NURSING INTERVENTIONS FOR PATIENTS HAVING GI DIAGNOSTIC ASSESSMENTProvide general information about a healthy diet and nutritional factors that can cause GI disturbancesProviding information about the test and the activities required of the patientAlleviating anxietyHelp patient cope with discomfortEncourage family members to offer emotional support to patient during the testAssess for adequate hydration before, during and immediately after the procedure and provide education about maintenance of hydration

DIAGNOSTIC ASSESSMENTBlood TestsCBC, CEA, Liver function tests, serum cholesterol, and triglycerides

May reveal alterations in basal metabolic function and severity of a disorderStool TestsInspect specimen for consistency and color, occult blood (Hematest), fecal urobilinogen, fat, nitrogen, parasites, pathogens, food residues and other substances.

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

What stool test is most frequently used in cancer screening programs and for early cancer detection?DIAGNOSTIC ASSESSMENTFalse positive HEMATEST may result if patient eat

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

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

False negative result: ingestion of Vit. C supplements or foodDIAGNOSTIC ASSESSMENTOther occult blood tests that yield more specific and more sensitive readings include:

HemoQuant OTHER TESTS:Immunologic tests are more specific to human hemoglobin

Hemoporphyrin assays detect the broadest range of blood derivatives

Immunochemical test using antihuman antibodies that are extremely sensitive to human hemoglobin are available.DIAGNOSTIC ASSESSMENTBreath TestsHydrogen breath test – evaluate carbohydrate absorption and diagnosis of bacterial overgrowth in the intestine and short bowel syndrome.

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

Urea breath test – detect presence of Helicobacter pylori which causes peptic ulcer disease.4. Abdominal UltrasonographyNoninvasive diagnostic technique which uses high-frequency sound waves.

Used to indicate the size and configuration of abdominal structures.

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

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

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

Endoscopic ultrasonography – gives direct imaging of a target area.

Patients fasts for 8-12 hours before the test

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

If barium studies are to be performed, nurse should make sure they are scheduled after this test…..why?5. DNA Testing – Pre clinical diagnosis to identify persons who are at risk for certain GI disorders (gastric cancer, lactose deficiency, inflammatory bowel disease, colon cancer).6. Imaging StudiesX-ray and contrast studies Upper GI series or barium swallow> Double contrast studies – administration of thick barium suspension followed by tablets that release carbon dioxide in the presence of water. (Early superficial neoplasms are identified)> Enteroclysis – a double contrast study of the entire small intestine by infusing continuously of 500-1000ml of thin barium sulfate suspension followed by methylcellulose and observed through fluoroscopy. Up to 6 hours. For diagnosis of Partial small-bowel obstructions or diverticula.

7. Upper GI series or Barium SwallowNursing InterventionsPatient need to maintain low-residue diet for several days before the test.

NPO after midnight before the test.

Physician may prescribe laxative

Discourage smoking on the morning before the examination

Follow up care after the procedure, fluids must be increased, monitor patient’s stool color, laxative or enema may be needed.8. Lower Gastrointestinal Tract StudyBarium Enema

Barium is instilled rectally to visualize the lower GI tract.

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

Double contrast studies – barium enema with instillation of air.

Lower Gastrointestinal Tract StudyNursing Interventions:Emptying and cleansing the lower bowel.

Low residue diet 1-2 days before the test

Clear liquid diet and laxative the evening before

Cleansing enemas until returns are clear the following morning

Barium enemas should be scheduled before any upper GI studies.

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

Administers enema or laxative after test to facilitate barium removal, Increase fluid intake.9. Computed Tomography (CT) ScansProvides cross-sectional images of abdominal organs and structures. Multiple x-ray images are taken for many different angles.Nursing Interventions:Patient should not eat or drink for 6-8 hours before the test.

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

Barium studies should be performed after CT scanning.10. Magnetic Resonance Imaging (MRI)Noninvasive technique that uses magnetic fields and radio waves to produce an image of the area being studied.

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

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.

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

Remove all jewelry and other metals

Warn patients on the close-fitting scanners which may induce feelings of claustrophobia and the machine will make a knocking sound during the procedure.11. Scintigraphy (Radionuclide imaging)Use radioactive isotopes (technitium,iodine and indium) to reveal displaced anatomic structures, changes in organ size and presence of neoplasms, cysts or abscesses.

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

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

Abnormal concentrations of blood cells are detected at 24 and 48 hours intervals12. Gastrointestinal Motility StudiesUsed to assess gastric emptying and colonic transit time.

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

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

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

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

If with chronic diarrhea, may be evaluated at 8-hour intervals. 13. Endoscopic ProceduresFibroscopy/ EsophagogastroduodenoscopyAnoscopyProctoscopySigmoidoscopyColonoscopySmall-bowel enteroscopyEndoscopy through ostomy

ENDOSCOPIC PROCEDURESEGDAfter 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.

ENDOSCOPIC PROCEDURESEGDUse 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

ENDOSCOPIC PROCEDURESEGD: Nursing InterventionsThe 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.

ENDOSCOPIC PROCEDURESEGD: Nursing InterventionsPosition 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

ENDOSCOPIC PROCEDURESEGD: Nursing InterventionsAfter 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

Fiberoptic ColonoscopyDirect 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

Fiberoptic ColonoscopyUsually 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.

Fiberoptic ColonoscopyAdequate 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.

Fiberoptic ColonoscopyPatient 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.

Fiberoptic ColonoscopyNPO 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

Fiberoptic ColonoscopyImmediately 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.

Flexible Fiberoptic Sigmoidoscopy

Anoscopy, Proctoscopy and SigmoidoscopyVisualize 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.

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