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Nursing 272: Final Semester > Unit 3: Chp 55: Assessment of Gastrointestinal Function > Flashcards

Unit 3: Chp 55: Assessment of Gastrointestinal Function Flashcards

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1
Q

Health History: Questions regarding dietary practices

A
  • 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?
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2
Q

Health History: Questions regarding Nutrition

A
  • Do you take vitamins?
  • Any hx of vitamin deficiencies?
  • Completion of a food frequency questionnaire
  • Completion of nutritional screening tool (MUST)
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3
Q

Health History: Questions regarding Oral Health

A
  • 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?
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4
Q

Health History: Questions regarding Preventative health

A
  • what are your exercise habits?
  • have you had Hepatitis vaccines?
  • have you had a colonoscopy or sigmoidoscopy?
  • what were the results?
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5
Q

Health History: Questions regarding weight changes?

A
  • 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
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6
Q

Health History: Questions regarding Appetite changes

A
  • have you had increased hunger or thirst?

- any early feeling of fullness?

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7
Q

Health History: Questions regarding Stool changes

A
  • 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?
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8
Q

Health history: Questions regarding Pain

A
  • 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?
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9
Q

anorexia

A

loss of appetite

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10
Q

Hematochezia

A

bright blood in the stool

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11
Q

Melena

A

black, tarry stool

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12
Q

What does the physical assessment include?

A 
>head-to-toe assessment
>anthropometric measurements:
-height
-weight
-BMI
-waist circumference
-body composition
-skinfold measurements
-circumference measurements
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13
Q

Specific Diagnostic Studies

A
  • Serum albumin
  • Prealbumin
  • Transferrin
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14
Q

Serum Albumin

A
  1. 4 to 5.1 g/dL

- levels less than 3.5 = altered nutritional status; increases morbidity and mortality

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15
Q

Prealbumin

A

12 to 42 mg/dL

  • more accurate indicator of plasma proteins when compared w/ albumin
  • decreased levels associated w/ increased morbidity and mortality
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16
Q

Transferrin

A

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

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17
Q

Social History Questions to ask Upon Assessment

A
  • 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?
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18
Q

Medical History questions to assess the GI system

A
  • 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?
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19
Q

Surgical hx questions to assess the GI system

A

any hx of previous abdominal surgeries

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20
Q

Eructation

A

belching

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21
Q

Physical Examination Includes?

A
  • direct assessment of oral cavity
  • direct assessment of skin
  • indirect assessment of the underlying structures: intestinal tract, liver, kidney, spleen, and abdominal arteries
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22
Q

What should you do before proceeding with the actual physical examination?

A
  • 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
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23
Q

Proper position for best results of a physical assessment of abdomen

A
  • supine
  • arms relaxed at the sides
  • knees bent in order to promote relaxation of the abdomen
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24
Q

Correct Order of the Physical Assessment

A
  • Inspection
  • Auscultation
  • Percussion
  • Palpation
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25
Q

Normal Biological Changes of the GI system in the geriatric population

A
  • 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
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26
Q

Inspection of the Oral Cavity

A 
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
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27
Q

Inspection of the skin over the Abdomen

A

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

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28
Q

Inspecting the exterior portion of the anus

A

-note the color; darker than surrounding skin

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29
Q

Documentation after inspection

A
  • include a full description of the findings

- position should be recorded according to the anatomical locations

30
Q

Abnormal Findings upon Inspection of the Oral Cavity

A
  • 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
31
Q

Abnormal Findings when Inspecting the Abdomen

A
  • 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
32
Q

Hernia

A

displacement or protrusion of a part of the intestine

33
Q

Aneurysm

A

enlargement or bulging of an artery usually associated with weakening of the vascular wall

34
Q

Cullen’s Sign

A

blue or purple coloring around the periumbilical area
-associated w/ intra-abdominal bleeding
(think of Edward Cullen; vampire bite mark on stomach)

35
Q

Inspection of an Ostomy: The Three “S”

A
  • Skin
  • Stoma
  • Stool
36
Q

Inspection of an Ostomy: Skin

A
  • surrounding skin color of the stoma should be consistent w/ rest of the abdomen
  • lesions or excoriations should be described and documented
37
Q

Inspection of an Ostomy: Stoma

A
  • assess for color and consistency

- stoma should be pink and moist

38
Q

Inspection of an Ostomy: Stool

A
  • 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
39
Q

What is the purpose of auscultation of the abdomen?

A

indirectly assesses bowel sounds and the vascular integrity of the arteries

40
Q

Why do we auscultate the abdomen before percussion and palpation?

A

manipulation of the abdomen can result in an inaccurate interpretation of bowel sounds as being hyperactive, so auscultation is completed after inspection

41
Q

Why do we auscultate the abdomen before percussion and palpation?

A

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

42
Q

What part of the stethoscope is considered best for auscultating high-pitched sounds such as bowel sounds?

A

Diaphragm

43
Q

Where is the starting point for auscultation of the abdomen?

A

RLQ

-bowel sounds are normally present in the RLQ at the ileocecal valve

44
Q

How to Auscultate the Abdomen

A
  • 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
45
Q

What are Normal Bowel Sounds

A
  • range from low- to high-pitched gurgling

- frequency of bowel sounds occurs at a rate of 5 to 30 times/min

46
Q

Determining Absence of Bowel Sounds

A

auscultate each quadrant for a minimum of 5 minutes

47
Q

Frequency of intestinal movement and quality of sound can be influenced by what factors?

A
  • timing of food intake
  • mobility
  • medications
  • neurological disorders
  • electrolyte imbalance
48
Q

Causes of Hypoactive Bowel Sounds

A
  • anesthetics
  • opioids
  • anticholinergic medications
  • constipation
  • ileus
49
Q

Ileus

A

absence of normal gastrointestinal mobility

50
Q

Causes of Hyperactive Bowel Sounds

A
  • secondary to the actions of cholinergic medications

- infectious and inflammatory bowel disorders

51
Q

What part of the stethoscope is used to hear low-pitched sounds?

A

the bell

  • the abdominal arteries (abdominal aorta, renal, iliac, and femoral arteries) can be indirectly assessed w/ the bell
  • can hear bruits w/ bell
52
Q

Bruit

A

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
53
Q

Abnormal Findings when Auscultating the Abdomen

A
  • 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
54
Q

Why do we Percuss the Abdomen

A

the size of the organs is ascertained though percussion and palpation
-require quiet environment and a skilled practitioner

55
Q

Things to Consider when Percussing the Abdomen

A
  • 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
56
Q

How to Percuss the Abdomen

A
  • 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
57
Q

What should you hear when percussing over the intestinal area?

A

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

58
Q

What should you hear when percussing over the liver or stomach?

A

dullness, a flat sound

-sound similar to the sound produced when tapping a balloon filled w/ water

59
Q

When percussing, when do you hear dullness?

A
  • 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
60
Q

Abnormal Findings in Percussion

A
  • 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
61
Q

Tympany

A

drum-like sound

-percussion

62
Q

Dullness

A

flat sound

-percussion

63
Q

Why do we palpate the Abdomen?

A
  • evaluate underlying structures
  • assess for abdominal tenderness
  • assess for abdominal tone
64
Q

Where is the starting point for palpation?

A

away from any areas of discomfort stated by the patient

65
Q

Light Palpation

A

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

66
Q

Deep Palpation

A
  • allows practitioner to assess size and consistency of kidney, liver, and spleen
  • performed by advanced practice nurses or providers
67
Q

Hooking technique

A

advanced practice skill used to assess the edge of the liver

68
Q

Heaptomegaly

A

enlarged liver

69
Q

Organomegaly

A

generalized enlargement of organs

70
Q

Abnormal Findings Upon Palpation

A
  • A rigid abdomen = pain, guarding, or peritonitis (inflammation of peritoneal cavity)
  • A mass = tumor, aneurysm, or hernia
71
Q

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

A

D. Supine w/ arms at the side and knees flexed

Nursing 272: Final Semester (79 decks)

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