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
Nausea & Vomiting: Interventions x 2 (6 x egs)
- correction of fluid & electrolyte imbalances
- anti-emetic meds
Options:
Promethazine; H1 antag; O/IM/IV
Metoclopramide; D2 + 5-HT3 antag; O/IM/IV
Prochlorperazine; D2 central antag; O/IM/PR
Domperidone; D2 peripheral antag; O
Haloperidol; D2 central; O/IM
Ondansetron; 5-HT3 antag; O/IM/IV/SL
Nausea & Vomiting: complications x 6
- dehydration
- metabolic alkalosis
- hypokalaemia
- aspiration
- muscular tear of gastro-oesophageal junction (Mallory-Weiss Syndrome)
- rupture of oesophagus (Boerhaave Syndrome)
Nausea & Vomiting: Ed x 2 & Referral x 2
Advice/Ed:
- small, regular oral fluid intake
- if unable to tolerate oral fluids & becoming dehydrated (symptomatic) seek further assistance
Referral:
- vomiting not ceased in 24hr period
- concern of/around sinister cause
Diarrhoea: acute x 3 Vs chronic x 2
Acute:
- sudden onset, usually last 24-48hrs,
- usually due to viral agents; adults - norovirus;
kids - rotavirus
- travellers diarrhoea; bacterial
Chronic:
- when assoc w malabsorption or inflammation always requires investigation & referral!
- major causes; IBS, Crohn’s Dx, Whipple’s Dx
Diarrhoea: Clin Ass x 8, S&S x 4, & invest x 2
Assessment
- look for weight loss
- clubbing
- anaemia
- oral ulcers
- rashes & abdominal scars
- assess severity of dehydration
- feel for enlarged thyroid or abdo mass
- detailed Hx !!
Common symptoms:
- fever
- abdo pain/cramping
- vomiting
- dehydration
Investigation
- stool sample (min 3 should be sent to lab for culture)
- if Dx still unclear, GP for further investigation
Diarrhoea: Red Flags x 6 & comps x 4
Red Flags:
- unexpected weight loss
- persistent/unresolved diarrhoea
- fever
- overseas travel
- severe abdo pain
- fam Hx bowel CA or Crohn’s Dx
Complications
- dehydration
- electrolyte disturbances
- abdo discomfort/cramping
- weight loss
Diarrhoea: Plan x 2, Interventions x 3, Advice x 3, & Refer x 2
Plan
- Acute presentations normally self limiting, req basic hygiene, hydration & anti-diarrhoea meds
- Chronic: rehydration & refer onto further care by GP
Interventions
- oral fluid & electrolyte replacement
- anti-diarrhoea meds
- Sig* dehydration: IV fluids
Advice/Ed
- rest
- hygiene practices
- avoid: fatty foods, dairy products, alcohol & coffee
Referral
- all chronic presentations
- refer acute PRN if necessary
Constipation: Dx criteria x 3
Idiopathic:
- simple constipation (faulty diet, bad habits)
- slow transit constipation (primarily in women)
- normal transit constipation (IBS)
Constipation: Hx x 8, exam, invest x 2, refer x 2
Hx
- ask Pt to define exactly what they mean
- stool consistency
- frequency
- ease of evacuation
- pain on defecation
- presence of any blood or mucus
- dietary Hx
- medical Hx
Exam
- abdominal exam
Investigation
- haematological; Hb & ESR (erythrocyte sedimentation rate: inflamm marker)
- stools for Occult Blood (guaiac test)
Refer
- biochemistry
- radiology
Constipation: Red flags x 5 & comps x 4
Red Flags
- neoplasms (primary or extrinsic malignancies pressing on the bowel)
- recent change in bowel habits
- recent constipation in Pt’s <40
- rectal bleeding
- fam Hx CA
Complications
- faecal impaction
- bowel obstruction
- haemorrhoids
- anal fissure
Constipation: plan acute Vs age, intervent, advice x 6, refer
Plan
- acute presentations: be mindful of Red Flags
- constipation in the elderly: common prob w tendency for idiopathic constipation to increase w age, along w chances of developing organic Dx; colorectal CA
Other issues assoc+ w ageing
- faecal impaction w decreased mobility/be found pts
- constipation & Parkinson’s Dx
- long term use of laxatives
Intervention
- advise & refer to GP for investigation & management
Advice:
- adequate exercise, esp walking
- develop good habit: answer call to defecate immediately
- don’t miss meals - food stimulates motility
- avoid laxatives & codeine compounds
- encourage oral fluid intake (H2O & prune juice etc)
- eat optimal bulk in diet: veg, salads, cereals, fruit, wholemeal bread
Refer
- most cases will req referral to GP to investigate & manage
Rectal prolapse: Clin feat x 5, Dx x 1
Clinical features
- mucus discharge
- bleeding
- tenesmus (feeling of incomplete emptying)
- solitary rectal ulcer
- faecal incontinence
Dx
- visualisation of the prolapsed part
Rectal prolapse: plan x 2, intervent x 2, refer
Plan
- complete prolapse, only surgery is an option
- partial prolapse; try intervention
Intervention
- apply generous amount of granulated sugar over the prolapse (often effective in reducing oedema within 15mins)
- using a gloved hand, apply gentle but steady pressure on the prolapse & push upward
Refer
- if unable to be reduced, recurs, or if ischaemia or gangrene suspected: emergency consult & ED
UTI: uncomp Vs comp, Ass x 1-5; 1-3; + 2
Uncomp: non-pregnant women (rarer in men) w no structural abnormalities - e.coli usually 70-95% of cases
Comp: anatomical/functional abnormalities & high risk of complications or Rx failure
Clin Ass:
Obtain complete Hx
- past episodes, Rx & effectiveness
- other sig* GU issues; calculi, prostate, renal
- PMHx - diabetes **
- STI Hx
- meds
Perform standard Obs
UA - mid stream if poss
Physical Ass:
- palpate abdo, suprapubic & flanks
- ? Inguinal lymph node enlargement
- consider STI investigations
UTI: man* x 2 + 3, Comps x 2, Adv x 5, Refer x 4
Management:
- urinary alkaliniser - Ural/citravescent (symptom relief only)
- discuss w GP re;
- trimethoprim,
- pregnant/pen sens: cephalexin, amox+clav OR norfloxacin
- ? Pyelonephritis; IV amp + gent! & consider HOSP
Complications/Red flags
- pyelonephritis
- sepsis
Advice:
- stress importance of extra fluids!
- if placed on meds: complete whole course
- post-coital voiding may assist in the future
- personal hygiene: wipe front to back
- avoir tight clothing
Refer:
- Men w confirmed UTI
- children <4yo w confirmed UTI
- suspected pyelonephritis
- Pts w severe haematuria
Paraphimosis: causes x 4, Clin ex x 5
Def: inability to reduce the proximal oedematous foreskin distally over the glans penis
Causes:
- retraction of the foreskin to perform formal Ass
- cleaning of the glans penis
- urethral catheterisation
- self-inflicted; piercing
Clin Exam:
- penile pain
- acute UTI or difficult passing urine
- glans penis is enlarged & congested w collar of oedematous foreskin
- constricted band directly behind the head of the penis
- penile shaft unremarkable
Paraphimosis: Red Flags x 2 & comps x 3
Red flags:
- glans necrosis
- balantitis
Complications:
- decreased perfusion to penile head
- pain
- necrosis
Paraphimosis: Man* x 5, Adv/Ed x 2, Refer
Management:
- pain management
- be cautious w Hx of difficult/invasive reduction prev OR anatomical abnormalities
- apply cold compress; reduce swelling
- attempt manual reduction
- immed* referral/Tx if unsuccessful!!
Adv/Education:
- important to maintain hygiene - but make sure foreskin is replaced back to original position
- uncircumcised; make sure Pt is aware of seriousness & need to present ASAP if recurs
Refer:
- all cases of unsuccessful manual reduction
Urinary Catheterisation: Ind* x 5, types x 3, Red Flag x 1
Gen* med* indications:
- pre-op/post-op drainage for surg or investigative procedure
- measure accurate output in critically ill Pts
- manage intractable urinary incontinence
- instilling meds (in some instances)
- resolving urinary retention issues (eg; prostate iss*)
Types:
Short term 0-14 days: latex/PVC (except in latex sens)
Short term 0-4 weeks: either PTFE or silver-coated latex
Long term 0-12 weeks: either 100% silicone, silicone coated, or hydrogel (coated w latex or silicone)
Lengths:
Males = 16-20FG
Females = 12-14FG
Red Flag:
- male Pts w a Hx of prostate surg* MUST go to ED for resolution of catheter issues
Urinary Cath: drainage points
Procedure:
- gain consent
- place bluey under collection chamber
- hand hygiene & don PPE
- open drainage tap * be sure nothing touches the collection bottle though!!*
- close drainage tap
- wipe drainage pipe w alco* swab before relocating to secure position
Post procedure:
- perform any req tests (may need 2 x samples)
- discard materials into Clin Waste bin
- perform hand hygiene
- notes findings & document results
Meatal cleansing:
- recommended that Pt does this 1-2 x daily
- warm soapy water is often effective
- if req* to do this; consent, privacy, PPE, & perform
Cath Problem: UTI; cause x 5, act x 2
Causes:
- poor aseptic technique
- inadequate urethral cleaning
- contamination of catheter tip
- poor handling of drainage system
- breaking the closed system
Action:
- obtain CSU
- review catheterisation care & technique
Cath Problem: Urethral muscular trauma; cause x 4, Act x 3
Causes:
- incorrect catheter size
- poor technique
- movement of catheter
- creation of a false passage
Action:
- re-catheterisation (consider Tx for review!)
- check catheter type ? Sensitivity = replace w 100% silicone
- even if still draining & continues to bleed; TX!
Cath Problem: no drainage post Cath; causes x 4, act x 3
Causes:
- incorrect ID of female external meatus
- blockage of catheter
- empty bladder
- dehydration
Action:
- Check to see if sited properly; if not, replace
- manage as blocked cath
- check FBC to discount dehydration as cause
Cath Problem: crusts around meatus; cause, act
Cause:
- increased secretions collect & form crust
Action:
- encourage daily meatal washing & post BO - soap & water OR saline
Cath Problem: falling out; causes x 4, act x 3
Causes:
- bladder spasm
- balloon deflated
- catheter traction
- reduce bladder neck/urethral tone
Action:
- check balloon is inflated
- secure catheter to leg to prevent pull
- teach pelvic floor exercises
Cath problem: blocked; causes x 2, Act x 2
Causes:
- is it kinked?
- mucous, bacteria or debris
Action:
- straighten out external apparatus
- re-catheterise
SPC: advantages x 6, risks/disadv x 7
Advantages:
- reduced risk of UTI
- urethral integrity maintained
- clamping of Cath* allows for normal voiding to resume post-op
- reduced pain/discomfort
- no risk of urethral trauma, necrosis, or cath induced urethritis
- easier access for cleaning & maintenance
Risks/disadvantages:
- risk of bowel perforation
- haemorrhage at time of insertion
- infection
- swelling
- encrustation
- pain/discomfort
- poss long term risk of SCC
SPC: care
Initially: care for wound as surg drain, 7-10/7 to heal, then soap & water
Some services: baclofen 30mins prior to change (esp; MS, SCI, brain injured)
If having issues: consult GP prior to change - poss Abx prior to change 1/52 later
If it falls out: be safe! Only 20-30mins to replace, or HOSP!!
SPC: advice; when to call x 7
When to seek help:
- no urine or very little flowing into bag for >/= 4hrs
- new pain in belly or pelvic area
- urine has changed colour: cloudy, bloody, malodorous or blood clots
- insertion site becomes; irritated, swollen, red, tender, or pus draining
- urine leaking from insertion site
- signs of kidney infection; fever >/= 38*C or back/flank pain
- symptoms; nausea/vomiting/shaking chills
