Unit 3: Chp 55: Assessment of Gastrointestinal Function Flashcards
Health History: Questions regarding dietary practices
- Who prepares the food in your home?
- Do you fast for cultural or religious reasons?
- Do you have any dietary restrictions d/t religious or cultural practices?
- How often do you eat?
- What do you consider to be healthy or unhealthy foods?
- Do you use food to treat illnesses?
- Any food intolerances?
- Any food allergies?
Health History: Questions regarding Nutrition
- Do you take vitamins?
- Any hx of vitamin deficiencies?
- Completion of a food frequency questionnaire
- Completion of nutritional screening tool (MUST)
Health History: Questions regarding Oral Health
- Do you see a dentist?; How often per year?
- Do you have a hx of dental caries or cavities?
- Do you wear dentures?
- Do you have gum disease?
- Have you been treated for oral candidiasis or oral cancer?
- Do you have difficulty swallowing or suffer w/ chronic hoarseness?
Health History: Questions regarding Preventative health
- what are your exercise habits?
- have you had Hepatitis vaccines?
- have you had a colonoscopy or sigmoidoscopy?
- what were the results?
Health History: Questions regarding weight changes?
- have you had any unexplained weight loss or weight gain?
- do you diet frequently?
- any binging or purging?
- do you ever make yourself vomit?
- any hematemesis (blood in emesis)/ Hemoptysis (blood in sputum)
- calculate BMI
Health History: Questions regarding Appetite changes
- have you had increased hunger or thirst?
- any early feeling of fullness?
Health History: Questions regarding Stool changes
- how often do you have a bowel movement?
- when was your last bowel movement?
- have you noticed any changes in color, consistency, or odor?
- have you noticed any bright red blood?
- have you noticed undigested food?
- any laxative use?
- frequent flatus?
Health history: Questions regarding Pain
- where is the pain?
- how often do you have pain?
- when do you have pain?
- what have you done to relieve the pain?
- what are the characteristics of your pain?
- do you experience pain before or after eating meals?
- do you experience pain w/ defecation?
anorexia
loss of appetite
Hematochezia
bright blood in the stool
Melena
black, tarry stool
What does the physical assessment include?
>head-to-toe assessment >anthropometric measurements: -height -weight -BMI -waist circumference -body composition -skinfold measurements -circumference measurements
Specific Diagnostic Studies
- Serum albumin
- Prealbumin
- Transferrin
Serum Albumin
- 4 to 5.1 g/dL
- levels less than 3.5 = altered nutritional status; increases morbidity and mortality
Prealbumin
12 to 42 mg/dL
- more accurate indicator of plasma proteins when compared w/ albumin
- decreased levels associated w/ increased morbidity and mortality
Transferrin
215 to 365 mg/dL in males
250 to 350 mg/dL in females
-important in nutritional assessment b/c of transferrin’s role in iron binding and transport
-decreased levels associated w/ infection, kidney disease, hepatic damage, and indicative of insufficient protein in diet in patients w/ malnourishment
Social History Questions to ask Upon Assessment
- do you smoke?
- do you use street drugs?
- do you use OTC medications?
- do you use herbals?
- do you drink alcohol?
- recent antibiotic use?
- any recent international travel?
Medical History questions to assess the GI system
- do you have a hx of previous heart attacks, chest pain? Parkinson’s disease, sickle cell disease? Sjogren’s syndrome?
- do you have a hx of diabetes, multiple sclerosis? Crohn’s disease? Irritable bowel disorder? Gastroesophageal reflux disease (GERD)?
- do you have a hx of anorexia nervosa? bulimia? depression? familial adenomatous polyposis? celiac disease?
Surgical hx questions to assess the GI system
any hx of previous abdominal surgeries
Eructation
belching
Physical Examination Includes?
- direct assessment of oral cavity
- direct assessment of skin
- indirect assessment of the underlying structures: intestinal tract, liver, kidney, spleen, and abdominal arteries
What should you do before proceeding with the actual physical examination?
- consider information collected during the health hx
- individual preferences, along w/ religious, cultural, or geriatric considerations may require the nurse to alter the approach to the examination
- some people, base on cultural or religious reasons, are uncomfortable w/ exposing the abdominal area or are sensitive to touch, which can lead to contraction of the underlying musculature in the abdomen, giving the false appearance of abdominal rigidity
- in assessing the older adult, important to recognize age-related changes to GI system
- clearly explain all aspects of the examination and provide the patient a private and comfortable environment
Proper position for best results of a physical assessment of abdomen
- supine
- arms relaxed at the sides
- knees bent in order to promote relaxation of the abdomen
Correct Order of the Physical Assessment
- Inspection
- Auscultation
- Percussion
- Palpation
Normal Biological Changes of the GI system in the geriatric population
- esophageal stiffening
- decreased peristaltic movement of the esophagus
- decreased gastric emptying
- decreased bile synthesis
- widened common bile duct
- increased cholecystokinin secretion
- distention and dilation of pancreatic ducts
- decreased weight of pancreas
- decreased sensitivity of pancreatic B cells to glucose
- decreased lipase production
- decrease in number and size of hepatic cells
- decrease in liver enzyme activity and cholesterol synthesis
- decreased peristalsis
- decreased mucus secretion in the large intestine
- decreased elasticity of the rectal wall
- decreased sensation of rectal wall distention
- decreased percentage of water weight
Inspection of the Oral Cavity
offers insight into gastrointestinal and oral health >with a bright light, assess: -oral mucosa -gums -tongue -general repair of dentition -jaw strength -ability to swallow
Inspection of the skin over the Abdomen
provides valuable information about the underlying structure
>using indirect lighting and tangential views, nurse inspects the skin for:
-color
-striae
-lesions
-presence of superficial vessels
-scarring
>Contour and Shape of the abdomen are noted
-abdomen should be slightly concave to round
-assess for fullness at the sides
-a rounded abdomen from obesity can be confused w/ abdominal distention and requires further assessment through percussion and palpation
-in thin patients, normal to note a midline pulse
Inspecting the exterior portion of the anus
-note the color; darker than surrounding skin
Documentation after inspection
- include a full description of the findings
- position should be recorded according to the anatomical locations
Abnormal Findings upon Inspection of the Oral Cavity
- bleeding or lesions on the underside of the mouth may = oral cancer
- lesions on the tongue can impair taste and appetite or impair the ability to swallow; contributes to a decreased nutritional status
- missing teeth or dental pain can lead to malnutrition
Abnormal Findings when Inspecting the Abdomen
- Bugling masses on the abdomen may indicate tumors or hernias
- Pulsatile masses may indicate aneurysms
- Striae (stretch marks) may be seen with a rapid change in weight; also in endocrine disorders
- Jaundice of the skin or sclera of eyes, or superficial vessels indicate presence of liver disease
- blue or purple coloring (Cullen’s sign) around the periumbilical area is associated with intra-abdominal bleeding
- presence of stomas should be noted, including their color and size
- visible swollen, protruding veins underlying the skin of the anus are indicative of hemorrhoids
Hernia
displacement or protrusion of a part of the intestine
Aneurysm
enlargement or bulging of an artery usually associated with weakening of the vascular wall
Cullen’s Sign
blue or purple coloring around the periumbilical area
-associated w/ intra-abdominal bleeding
(think of Edward Cullen; vampire bite mark on stomach)
Inspection of an Ostomy: The Three “S”
- Skin
- Stoma
- Stool
Inspection of an Ostomy: Skin
- surrounding skin color of the stoma should be consistent w/ rest of the abdomen
- lesions or excoriations should be described and documented
Inspection of an Ostomy: Stoma
- assess for color and consistency
- stoma should be pink and moist
Inspection of an Ostomy: Stool
- consistency of stool is dependent on location of the stoma
ex: an ostomy located in the ileum will pass semiliquid stool
ex: stool from sigmoid colon will be formed
What is the purpose of auscultation of the abdomen?
indirectly assesses bowel sounds and the vascular integrity of the arteries
Why do we auscultate the abdomen before percussion and palpation?
manipulation of the abdomen can result in an inaccurate interpretation of bowel sounds as being hyperactive, so auscultation is completed after inspection
Why do we auscultate the abdomen before percussion and palpation?
manipulation of the abdomen can result in an inaccurate interpretation of bowel sounds as being hyperactive, so auscultation is completed after inspection
-stethoscope should be placed lightly on abdomen
What part of the stethoscope is considered best for auscultating high-pitched sounds such as bowel sounds?
Diaphragm
Where is the starting point for auscultation of the abdomen?
RLQ
-bowel sounds are normally present in the RLQ at the ileocecal valve
How to Auscultate the Abdomen
- start in RLQ
- moving in a counterclockwise position
- listen in each quadrant
- pay close attention to the quality of pitch and sound made by intestines
What are Normal Bowel Sounds
- range from low- to high-pitched gurgling
- frequency of bowel sounds occurs at a rate of 5 to 30 times/min
Determining Absence of Bowel Sounds
auscultate each quadrant for a minimum of 5 minutes
Frequency of intestinal movement and quality of sound can be influenced by what factors?
- timing of food intake
- mobility
- medications
- neurological disorders
- electrolyte imbalance
Causes of Hypoactive Bowel Sounds
- anesthetics
- opioids
- anticholinergic medications
- constipation
- ileus
Ileus
absence of normal gastrointestinal mobility
Causes of Hyperactive Bowel Sounds
- secondary to the actions of cholinergic medications
- infectious and inflammatory bowel disorders
What part of the stethoscope is used to hear low-pitched sounds?
the bell
- the abdominal arteries (abdominal aorta, renal, iliac, and femoral arteries) can be indirectly assessed w/ the bell
- can hear bruits w/ bell
Bruit
abnormal sounds heard upon auscultation of blood vessels
- whooshing sound of a bruit may = partial obstruction of the vessel
- avoid palpation if bruit is heard
- report finding to healthcare provider
Abnormal Findings when Auscultating the Abdomen
- Hypoactive bowel sounds = late indicator of obstruction
- Hyperactive bowel sounds = early indication of obstruction, diarrhea, or inflammatory bowel disorders
- Absent bowel sounds = paralytic ileus caused by mechanical or neurological dysfunction
- Bruit = arterial obstruction
Why do we Percuss the Abdomen
the size of the organs is ascertained though percussion and palpation
-require quiet environment and a skilled practitioner
Things to Consider when Percussing the Abdomen
- fingernail length should be short to avoid pinching or scratching the patient
- patient should be supine w/ legs partially bent, allowing for abdominal muscles to be in a relaxed position
How to Percuss the Abdomen
- RUQ
- the nurse places the nondominant hand parallel to the abdomen and firmly places an outstretched finger on the abdomen
- striking the outstretched finger w/ a finger from the dominant hand
- nurse continues this motion, moving in a clockwise fashion
What should you hear when percussing over the intestinal area?
tympany (drum-like sound)
-sound similar to the sound heard when percussing a balloon filled w/ air and should be the predominant sound of the abdomen b/c air rises in the intestines when patients are in a supine position
What should you hear when percussing over the liver or stomach?
dullness, a flat sound
-sound similar to the sound produced when tapping a balloon filled w/ water
When percussing, when do you hear dullness?
- over the liver or stomach
- an obese abdomen
- over the intestinal tract when filled w/ fecal matter
- over a full bladder
- in the presence of fluid accumulation in the abdomen
- ascites
Abnormal Findings in Percussion
- Tympany can be the predominant sound when abdominal gas is present
- Presence of fluid can displace air, and dullness is then the dominant sound
- Dullness can indicate constipation
Tympany
drum-like sound
-percussion
Dullness
flat sound
-percussion
Why do we palpate the Abdomen?
- evaluate underlying structures
- assess for abdominal tenderness
- assess for abdominal tone
Where is the starting point for palpation?
away from any areas of discomfort stated by the patient
Light Palpation
slightly pressing the pads of the fingers into the abdomen and gliding them over the abdomen in small, incremental, circular movements clockwise around the abdomen
Deep Palpation
- allows practitioner to assess size and consistency of kidney, liver, and spleen
- performed by advanced practice nurses or providers
Hooking technique
advanced practice skill used to assess the edge of the liver
Heaptomegaly
enlarged liver
Organomegaly
generalized enlargement of organs
Abnormal Findings Upon Palpation
- A rigid abdomen = pain, guarding, or peritonitis (inflammation of peritoneal cavity)
- A mass = tumor, aneurysm, or hernia
Connection Check: The nurse places the patient in which position for gastrointestinal assessment to promote relaxation of the abdominal muscles?
A. Sitting upright w/ arms relaxed in the lap and feet on the floor
B. Semi-recumbent w/ knees extended and arms at the sides
C. Side-lying w/ arms above the head and knees flexed
D. Supine w/ arms at the side and knees flexed
D. Supine w/ arms at the side and knees flexed
