Gastrointestinal Assessment Flashcards
GI Ass - general: inspect x 1 & gen* observe x 8
Inspect:
- Pt’s env for feeding tubes, stoma bags, drains etc
Observe:
- measure: height, weight, waist circum & calc BMI
- body habitus: obesity, weight loss, cachetic
- hydration status
- fever
- distress/pain
- muscle wasting
- jaundice
- abdo distension
GI Ass - Hands x 6, 1 x test & ass which Obs
- nail clubbing (IBS/cirrhosis/coeliac)
- koilonychia: spooning of nails (chronic iron deficiency)
- leukonychia: whitening of the nail bed (liver failure, enteropathy, hypoalbuminaemia)
- palmar erythema: reddening of palms (liver Dx/pregnancy)
- cigarette staining
- Dupuytren’s contracture: thickening of the palmar fascia; contracted phalanges (ETOH excess/liver cirrhosis)
Hepatic flap test (asterixis)
- hold hands out in front of them & look for tremor
- ask Pt to extend fingers up to ceiling & look for liver flap (hepatic encephalopathy/uraemia/CO2 retention)
- assess Pt’s pulse & BP here
GI Ass - Arms x 4 & Axillae x 3
Arms
- bruising (coagulation issues)
- petechiae (low platelets)
- excoriations (cholestasis)
- track marks (IVDU & Hep C/HIV risks)
Axillae:
- lymphadenopathy (infection/malignancy)
- hair loss (malnutrition/iron deficiency)
- Acanthosis nigricans (obesity/GI adenocarcinomas)
GI Ass - Eyes x 3 & Mouth x 4
Eyes
- jaundice (hepatitis/cirrhosis/biliary obstruction)
- conjunctival pallor (anaemia)
- xanthelasma (raised yellow deposits around eyelid; hyperlipidaemia)
(Ask Pt to Look Up/Down & check inside of lower eyelid)
Mouth
- angular stomatitis (inflamed red areas at Cnrs of mouth; iron def)
- oral candidiasis (iron def/immunodeficiency)
- mouth ulcers
- tongue: glossitis (red & swollen; iron def)
(Ask Pt to open mouth, stick tongue out, point tongue upward)
GI Ass - Neck x 2 & Chest x 3
Neck
- cervical lymph nodes (lymphadenopathy may indicate infection/metastatic malignancy)
- Virchow’s node: left subclavicular fossa (GI malig)
Chest
- spider naevi: > 5 = chronic renal Dx
- gynaecomastia (liver cirrhosis/spironolactone)
- hair loss (malnutrition/iron def anaemia)
Abdo Inspection: x 6 & 2 x signs
Scars:
- midline (laparotomy)
- RIF (appendectomy)
- R subcostal (cholecystectomy)
Masses:
- assess Size, Position, Consistency & Mobility
Pulsation:
- a central pulsation & expansive mass may indicate AAA
Cullen’s sign:
- bruising around umbilicus; retroperitoneal bleed
Grey-Turner’s sign:
- bruising in the flanks; retroperitoneal bleed
Distension (5 Fs)
- fluid/fat/flatus/faeces/foetus
Caput Medusa
- engorged para-umbilical veins; portal hypertension
Stomas
- LLQ (colostomy)
- RLQ (ileostomy)
- RLQ & urine (urostomy)
Abdo Palpation: light x 4 Vs deep x 5, organs x 5 + 1 other Dx
Ask re pain, prior to palpating!
Light Palpation:
- tenderness
- rebound tenderness (peritonitis)
- guarding
- masses
Deep Palpation
If any masses:
- Location
- Shape
- Consistency
- Mobility
- Pulsatility
Palpate Liver:
- start in RIF
- ask Pt to take deep breath w pressure on abdo
- feel for step, as liver edge passes under yr hand
- feel for degree of extension below the costal margin
- feel consistency of liver edge; smooth/irregular
- tenderness; suggestive of hepatitis
- pulsatility; can be cause by tricuspid regurgitation
Palpate Gall Bladder
- not normally palpable unless enlarged or obstructed
Look for Murphy’s sign:
- palpate right costal margin, mid-clavicular line
- ask Pt to take a deep breath
- as GB gets compressed under hand, Pt will instinctively guard it
- Positive Murphy’s sign; suggests cholecystitis
Palpate Spleen
- only palpable when 3 x normal size!
- work way up from RIF across abdo to L costal margin, w Pt taking deep breaths each step
Palpate kidneys:
- L hand behind Pt’s R flank
- R hand just below costal margin
- press fingers together from both sides to palpate kidney
- ask Pt to take a deep breath
- may feel the lower pole of the kidney moving inferiorly during inspiration
- Repeat on opposite side
Palpate Aorta
- using fingers from both hands, just above umbilicus at the border of the aortic pulsation
- Note movement of fingers
~ upward = pulsation
~ outward = expansile
Both suggestive of AAA
Palpate bladder
- empty bladder Not palpable
- enlarged/full bladder can be felt rising above pubic symphysis (?Urinary retention)
Abdo Percussion: 3 x organs + 1 test
Liver
- percuss from bottom to locate lower edge & from top down for superior edge: normal 6-12cm
Spleen
- same line as for splenomegaly [OR last intercostal space & percuss as Pt takes a deep breath]
Bladder
- percuss suprapubic region; differentiating suprapubic masses (bladder = dull, bowel = resonant)
Shifting dullness
- percuss Centre of abdo to flank until dullness noted
- keep finger there & ask Pt to roll onto side
- wait 30secs
- repeat percussion again
IF fluid was present, it should now be resonant (ascites)
- IF now resonant, percuss back to midline to assess how far fluid has shifted
Abdo Auscultation: 6 x locations
Bowel sounds
- normal = gurgling
- abnormal = tinkling (bowel obstruction)
- absent = no BS heard in 2 mins (ileum/peritonitis)
Bruits:
Aorta - 2/3s down from xiphoid & above umbilicus (AAA)
Renal arteries - 3cm superior & lateral to umbilicus (just proximal to the mid-clav line)
Iliac arteries - 3cm inferior & lateral to umbilicus
Hepatic artery - R costal margin, laterally, mid-clav line
Splenic artery - L costal margin, approx 2cm inferior & lateral, moving posteriorly to mid-clav line
OG/NG tube: indications x 5
Indications
- decompress stomach & upper bowel
- empty stomach of accumulated gas & fluid (lavage of toxic fluid)
- gain access to stomach contents for analysis
- gain access to upper GIT to admin meds
- provide enteral feeding
OG/NG tube: contraind* 1, comp 2, & long term comp x6
Contraindications
- NG route: nasal #s or suspected base of skull
Complications
- potential for aspiration
- nasopharyngeal trauma/ulceration
Long term feeding GIT comp:
- nausea
- vomiting
- diarrhoea
- constipation
- dehydration
- electrolyte disturbances
PEG tubes: general; only type Vs Tx!
ONLY simple Balloon PEGs can be attempted to be changed, within 20-30mins!!
All others to Hosp:
Bumper PEGs
Jejunostomy (J-tubes)
Low profile button in paeds
PEG complications: x 9 & BBS - hypergran
Complications
- pain at site
- infection of site
- aspiration
- leakage of stomach contents around tube site (Not working properly)
- bleeding/perforation into abdominal wall
- skin/gastric ulceration
- blocked PEG tube
- tube degradation
- dislodgement/malfunction of tube
- gastric fistula post removal
- granulation around insertion site
Buried bumper syndrome:
- bumper can become buried in abdo lining, external tube twists & then recoils (HOSP)
Hyper-granulation:
- referral to comm nursing for management w silver nitrate sticks (due to increased bacterial burden created)
PEG tube: general care; 10 + routine care & reg flushing
- ensure 2-5mm from external flange to skin level
- examine skin at site for irritation/infection
- note measured guide no @ end of external fixation device
- remove tube from fixation device & ease away from abdo
- No gauze/dressings under external flange!
- IF skin irritated: established site, warm soapy water; new site, saline
- ?barrier cream use; carnoseptine (zinc)
- ?broken skin; Conveen critic barrier (dries In powder form)… then Protact once skin healed.
REFER to comm nursing!!
-unless sutured, PEG should be moved in & out & rotated 360 degrees every 24hrs post initial insertion to prevent adhesion!!
- reattach the external fixation device & position as before according to markings on the tube
- Note: measured guide number at end of external fixation device
Routine care:
- performed by Pt & family 10/7 following initial insertion… asepsis not Req.
Regular flushing:
- maintain latency
- assist Pt to meet fluid req
Common GIT issues for PHC: x 5
- GORD
- nausea & vomiting
- diarrhoea
- constipation
- rectal prolapse
GORD: causes x 4, Clin S&S x 6, Red Flags x 11
Causes
- transient relaxation of lower oesophageal sphincter
- Meds: Ca2+ channel blockers, alpha-adrenergic antagonists, anticholinergic drugs
- Foods: chocolate, tobacco, coffee
- pregnancy
Clinical S&S:
- nausea
- bloating/belching
- heartburn
- acid regurg when lying flat at night
- water brash: mouth fills w saliva
- nocturnal cough
[Dx normally made on Hx, no further investigations need if No Red Flags]
Red Flags:
- pointers for upper GIT endoscopy
- haematemesis/melaena
- anaemia (new onset)
- dysphagia
- odynophagia (painful swallowing)
- vomiting
- unexplained weight loss >10%
- >50yo
- chronic NSAID use
- severe, frequent symptoms
- FHx of upper GIT/colorectal CA
GORD: Plan; stage 1 x 6; stage 2 x 3, comps x 5, advice, referral
Plan:
- simple lifestyle education & antacids
Stage 1:
- education & reassurance
- consider acid suppression/neutralisation
- look at better lifestyle choices (weight, smoking, alcohol, fatty/spicy food, coffee/choc, take time while eating)
- elevate Pt’s head for sleeping
- consider current meds & if alternatives can be tried
- antacids for acute relief, but not long term management
Stage 2:
- IF No relief after several weeks:
~ PPI for 4/52 - 30-60mins before bed
~ H2 antagonists, oral for 8/52
Note:
- some providers prefer PPI initially & step down
- primary presentation Must be Referred to GP
Complications
- oesophagitis +/- ulcer
- iron deficiency anaemia
- oesophageal stricture
- Resp: chronic cough, hoarseness, asthma
- Barrett oesophagus (from prolonged reflux)
Advice/Ed:
- as prev discussed
Referral:
- if primary presentation
- Red flags
- symptoms not relived w simple antacids
Nausea & Vomiting: common causes x 9
- medicines: chemotherapy and anaesthetics
- infections of the GIT
- bacterial toxins in food
- pregnancy
- alcohol intoxication
- motion sickness
- intestinal blockages
- migraine headaches
- head pathologies; or trauma & rising ICP
Nausea & Vomiting: Hx x 5, nature x 3, exam x 4, & Red Flags x 5
Hx:
- drug/alcohol intake
- possible psychogenic factors
- self-induced emesis
- weight loss
- other GIT symptoms
Nature:
- faeculent: GI obstruction
- blood: oesophageal, stomach, duodenal
- coffee-grounds: stomach or duodenal
Exam:
- detailed physical ass
- pregnancy test
- blood tests
- referral for radiology
Red Flags:
- marked pallor
- signs of hypovolaemia
- peritoneal signs
- headache, stiff neck, confusion
- distended, tympanic abdomen
