Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 39: Patient Assessment: Gastrointestinal System

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins History Subjective data from patient/significant other Speed depends on the degree of acuity Pain assessment (organized) –Pain is the fifth vital sign –Use an organized approach

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Organized Pain Assessment O = Onset (slow, fast) P = Precipitating factor (what causes it?; food, empty stomach, stress) Q = Quality (how the patient describes it; dull, achy, comes and goes) R = Radiation (where does it go? Usually referred pain) S = Severity (rate on 1 to 10 scale) T = Timing (how long does it last?)

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Common Pain Locations with GI Problems See Figure 39-2.

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Historical Data Past medical history Family history Personal/social contributing factors GI system review Nutritional assessment

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Physical Assessment Inspection Auscultation Percussion Palpation Equipment needed

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Inspection A keen observer learns the most Overall appearance Symmetry of lips, jaws Position gag reflex Abdomen divided into four quadrants –Tense, shiny skin –Shape and symmetry –Scars, ecchymoses –Ascites (measure abdominal girth)

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Auscultation

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Auscultation (cont.) Hearing bowel motility Always done before percussion and palpation, as they will increase the sounds if done first Start on right side below the umbilicus Should hear soft, bubbling sounds every 5 to 15 seconds –Borborygmi –Hypoactive bowel sounds

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question With a patient who has just undergone an open repair of a ruptured spleen, the nurse would expect to hear: A. Normal bowel sounds B. Absent bowel sounds C. Hypoactive bowel sounds D. Hyperactive bowel sounds

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. Absent bowel sounds Rationale: Immediately after major bowel surgery, the bowel stops working for a few days. Once the patient is no longer sympathetically stimulated and is out of bed and into a chair, bowel sounds will be become hypoactive and then normal after a few days if peristalsis returns.

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Percussion Air-, gas-, or fluid-filled organs Sounds are identified by tapping on that organ Sounds include: –Dull – over a fluid-filled organ like the liver –Tympanic – over a partially gas-filled organ like the stomach

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Palpation Palpate the parotid and submaxillary ducts Types of palpation –Light – done first to check for muscle tone and pain –Deep – done deeper by about 3 inches Rebound tenderness – deep palpation but let go quickly (can indicate peritonitis) Can locate masses –Ballottement – light rapid tapping against the abdominal wall

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Nutritional Assessment Use nutritional consults to assist in care Perform and evaluate daily weights Check for risk of negative nitrogen balance –Fever –Malnutrition –Burns –Long-term chronic debilitating illnesses

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Laboratory Studies Liver function tests (LFTs) –Bilirubin –Albumin –PTT, PT –Cholesterol Pancreatic lab tests –Amylase –Lipase –Triglycerides

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question In a patient with upper GI bleeding from esophageal varices due to long-standing liver disease, which of the following would be expected? A. Decreased PT, PTT B. Elevated albumin levels C. Elevated ammonia levels D. Decreased AST, ALT

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Elevated ammonia levels Rationale: In a diseased liver of a long-term alcoholic, the coagulation studies would be increased because the liver makes clotting factors. The ammonia levels would be high as the liver helps break down ammonia to urea. The albumin levels would be low as the liver produces these, and usually alcoholics don’t eat enough to get protein to make albumin. AST and ALT would be high, indicating damage to the hepatocytes.

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Laboratory Studies Stool studies –Occult blood –Ova and parasites (O & P) –Fat (steatorrhea)

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Radiological Studies Flat plate of the abdomen (x-ray) Upper GI (barium swallow) Barium enema (BE) Paracentesis Peritoneal lavage

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Endoscopic Studies: Visualization of the Bowel EGD (esophagogastroduodenoscopy) Colonoscopy Proctoscopy Sigmoidoscopy

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Question After a patient has a sigmoidoscopy, it is not necessary to check for the return of the gag reflex as this visualization is of the lower rectum and colon. A. True B. False

Copyright © 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer B. True Rationale: Sedation is not used during a sigmoidoscopy. Whenever sedation is used, as in a colonoscopy, until the patient can produce a gag, the nurse must protect the airway.