GI/GU Assessment

Question 1

History

Answer 1

• How often do you have a bowel movement? Do you have any diarrhea or constipation? Do you take laxatives? Are you urinating more than usual? When you need to urinate do you feel as if you cannot wait?
• Have you had any abdominal pain recently? Could you point to it? Have you noticed any bleeding during urination or defecation?
• Any nausea or vomiting? Do you have any food intolerance? Any changes to your appetite or weight? Any difficulty swallowing?
• Any history of gastrointestinal problems, such as ulcers, gallbladder disease, or have you had any operations in the abdomen?
• Any family history of inflammatory bowel disease or colorectal cancer? Any history of kidney disease, kidney stones or UTI’s
• Have you engaged in sexual activity in the last 6 months? Do you have a regular sex partner? Do you use precautions to reduce risk for STIs?
• are you currently taking any medications? Do you take herbal or natural supplements?
• Do you drink alcohol or smoke?
• I would like to know more about your diet could you please tell me what you ate yesterday starting with breakfast? Does your diet incorporate all the food groups according to “eating Well with Canada’s food guide?
• What is your diet pattern? Do you drink enough water to stay hydrated?

Question 2

Inspect

Answer 2

• could you please open your mouth, and shine the pen light and look to see if mucus membrane is pink and moist, look for any lesions or sores
• stand on the patient’s right side and look down at the abdomen. Then stoop or sit to gaze across the abdomen and determine the profile from the rib margin to the pubic bone.The contour normally describes the individuals nutritional state.Shine a light across the abdomen toward you or lengthwise across the patient and it should be symmetrical bilaterally. Step to the foot of the examination bed to recheck symmetry. Ask patient to take a deep breathe and notice the abdomen should stay smooth and symmetrical. Umbilicus is mid line and inverted with no sign of discoloration, inflammation or hernia, is not red or crusted.
• the surface of the skin is even, with no lesions or scars present. There is no redness or inflammation. Good skin turgor
• No abnormal pulsations are apparent in patient, there is respiratory movement in the abdomen
• she is quietly relaxed with a benign facial expression and slow even respiration

Question 3

Auscultate

Answer 3

• auscultate before palpation beginning in the RQL using the diaphragm
• verbalize normal bowel sounds, gurgling and cascading sounds. A silent abdomen is uncommon you must listen for 5 minutes before deciding bowel sounds are completely absent
• Using the bell of the stethoscope and a firmer pressure check the aorta, renal, iliac, and femoral arteries. Note any presence of vascular sounds or bruits, usually no sound is present, if bruit is do not palpate

Question 4

Palpate

Answer 4

Perform light palpation to asses the texture, temperature, moisture, swelling and rigidity, pulsation and presence of tenderness or pain.