Related to GI system. Adult health nursing

1. Sub: Adult Health Nursing –I
Unit: I
Assessment of the GI System
NAJEEB AHMED DAYO
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2. GI Focused Assessment Health History
SocialCultural Factors
Bowel Elimination Pattern
Use of Alcohol, street drugs, Caffeine
Diet and Nutrition (Food Allergies)
Medication Use: prescription
Family History of GI Problems
Previous GI Problems
Current GI Symptoms
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3. GI Focused Assessment Health History
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4. Health History
▫ Abdominal pain, dyspepsia
▫ Nausea and vomiting,
▫ Constipation, diarrhea, gas
▫ Fecal continence
▫ Change in bowel patterns, characteristics of stool
▫ Jaundice (yellowing of the skin, sclera, palms)
▫ History of GI surgery or problems,
▫ Appetite and eating patterns, nutritional assessment
▫ Weight patterns
▫ Medications- (NSAIDs)
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5. Abdominal Pain
Visceral
From internal organ (dull, general, poorly localized)
Parietal
From inflammation of overlying peritoneum (sharp,
precisely localized, aggravated by movement)
Referred
From a disorder at another site
Pain is referred to a site where the organ was located in fetal
development ... and the nerves persist in referring sensations
from the former locations.
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6. Common Sites of Referred Pain
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7. Common GI Symptoms and Causes
• Upper GI-black tarry, Lower GI bright red,
rectal or anal, streaks
Blood
•Food intolerance or gall bladder
Gas and
Bloating
• Peritoneal irritation, infection hepatobiliary
disorder, mechanical obstruction, increased
ICP, vestibular, meds (chemo)
Vomiting
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8. FLS (funny looking stool)
• Dark brown
Meat protein or cocoa
• Red
Beets/carrots
Barium
• Black
Iron, bismuth
• Insufficient bile, gallbladder or pancreas
problem
Fatty/floaty/ greasy
Clay/grey
Milky white
Bile duct or pancreas problem
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9. Physical Assessment
Abdomen
The patient lies supine with knees flexed slightly to
relax the abdomen
Empty bladder
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10. Physical Assessment Abdomen
1. Inspection
2. Auscultation
3. Percussion
4. Palpation
This is done because percussion and palpation can
increase peristalsis and might give a false interpretation
of bowel sounds.
http://www.prohealthsys.com/physical/abdominal_exam.php
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11. Abdominal Assessment
▫ Diaphragm (Bowel sounds)
▫ Bell (Vascular sounds, bruits)
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13. Quadrants of the Abdomen Reference
points for examination & documentation
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14. Inspection Contour (character)
• Generalized abdominal distention: gas retention
or obesity
• Lower abdominal distention: bladder distention,
pregnancy, ovarian mass
• General distention and an averted umbilicus:
ascites (fluid) and tumors
• A scaphoid (sunken) abdomen: malnutrition or
muscle replaces fat
*normal abdomen is described as flat and soft
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15. Auscultation (Bowel Sounds)
Normoactive
• Gurgling or clicking
sounds occur every
5-15 seconds
Hypoactive
• 1-2 sounds in 2
minutes
• Absence of sound
no sounds in 5
minutes per
quadrant(after
abdominal surgery
or with
inflammation of
peritoneum)
Hyperactive
• Loud
• High pitched
• Rushing
• Tinkling sounds
that signal
increased motility)
Borborgymus: hyperperstalsis (“stomach growling”) Bowel sounds are
estimated, not an actual count per minute
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17. Order of Auscultation, Percussion, Palpation,
1. RLQ ->
2. RUQ ->
3. LUQ ->
4. LLQ
Listen for 1 minutes and if no bowel sounds are heard, listen for up to 5
minutes (per quadrant)
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18. Vascular Sounds
• Using the bell of your stethoscope (low pitch sounds
• Listen for
“Bruit” = blowing sound;
(stenosis or artery occlusion)
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19. Palpation
• Light
▫ ½ inch deep
• Deep
▫ 2-3 inches deep
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20. Light Palpation: use four fingers,
depress 1/2 inch; move clockwise to
form an overall impression
Abnormal= muscle guarding; rigidity;
tenderness
Deep Palpation: use four fingers,
depress 2-3 inches; move clockwise
Normal: mild tenderness over sigmoid
colon but no other areas tender
Bimanual Palpation: use two hand with obese/large abdomen
Voluntary guarding if
cold, tense, ticklish
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21. Reference
• Smeltzer. S. C., Bare. B.G., Hinkle. J. L & Cheever.
K. H. (2010). Textbook of Medical – Surgical
Nursing. Vol -I (12th Ed.). Lippincott Williams &
Williams. Tokyo.
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