Week 5 Nursing Flashcards
gastrointestinal health history
Focus on symptoms common to gastrointestinal dysfunction:
* Pain
* Indigestion
* Intestinal gas
* Nausea and vomiting
* Haematemesis
* Changes in bowel habits
* Stool characteristics
Information about previous GI disease
* Past and current medication use
* Previous GI treatment or surgery
* Diagnostic studies or treatments
Dietary history to assess nutritional status
* Changes in appetite and eating patterns
* Unexplained weight loss or gain
Pain
* Can be a major symptom of GI disease
* Character, duration, pattern, frequency, location, distribution of referred pain and time of time
Indigestion
* Upper abdominal discomfort associated with eating
* Related to gastric peristaltic movements
* Can result from:
- disturbed nervous system control of the stomach
- disorder in the GI tract
- fatty foods
- highly seasoned foods
Intestinal gas accumulating in GI tract
* Belching - expulsion of gas from stomach
* Flatulence - expulsion of gas from small intestine and colon
Excessive flatulence related to:
- gallbladder disease or food
- food intolerance
Nausea and vomiting
* Preceded by nausea
* Triggered by odours, activity or food intake
* Emesis varies in colour, undigested food or blood (haematemesis)
* Emesis with bright red blood – vomiting soon after haemaorrhage
* Coffee ground emesis-blood retained in stomach with digestive enzyme action
Changes in bowel habits and stool characteristics
* May signal colon disease
* Medications or food- can change the appearance of food
* Blood in stool – needs investigation
* Upper GI bleed- produces tarry black stool (melaena)
* Lower GI bleed- bright red blood in stool
Abnormal stool characteristics
* Bulky, greasy, foamy stool that are foul in odour
* Clay coloured stool lacks urobilin
* Mucus threads or pus
* Small, dry, rock hard masses ( called scybala)
* Loose , watery stool
Upper GIT
▪ Inspect
– Lips
– Tongue, buccal mucosa
– Teeth and gums
– Pharynx
▪ Look for ulcers, nodules, swelling, discolouration and inflammation
▪ Palpation-suspicious areas
Abdominal Quadrants and Organs - Left
LUQ
* Stomach
* Spleen
* Left lobe of liver
* Duodenum
* Body of pancreas
* Left kidney and adrenal
* Splenic flexure of colon
* Part of descending and transverse colon
LLQ
* Part of descending colon
* Sigmoid colon
* Left ovary and fallopian tube
* Left ureter
* Left spermatic cord
Abdominal Quadrants and Organs - Right
RUQ
* Liver
* Gall bladder
* Duodenum
* Head of pancreas
* Right kidney and adrenal
* Hepatic flexure of colon
* Part of ascending and transverse colon
RLQ
* Caecum
* Appendix
* Right ovary and tube
* Right ureter
* Right spermatic cord
Abdominal Physical Assessment
▪ Empty bladder
▪ Relaxed patient
▪ Comfortable position, supine with one pillow, legs bent
▪ Arms at side
▪ Explain to patient to indicate any areas of tenderness or pain and these are assessed last
▪ Warm hands, warm stethoscope, short nails
▪ Watch patient’s face for reactions
Abdominal Inspection
▪ Visualise the organs in each of the regions/ quadrants of the abdomen, as you examine:
– skin colour or scars
– umbilicus - enlarged, everted or sunken
– contour and symmetry bulging or distention
– masses
– surface movement pulsations, peristalsis
Abdominal Auscultation
▪ Listen prior to percussion and palpation. Why ?
▪ Warm stethoscope prior
▪ Listen in all four quadrants for 2-5 minutes, begin in the RLQ
▪ Listen for bowel sounds in each quadrant (5 – 35 times per minute)
Document as normal, hypoactive or hyperactive
Abdominal Palpation
▪ Palpate all four quadrants
▪ Use pads of fingers to depress 1 – 2 cm
▪ Keep hand and forearm flat, keep fingers together
▪ Use a light dipping motion, avoid short finger jabs
▪ Relax abdominal muscles
▪ Palpate over painful area last
▪ Light palpation identifies:
– muscular resistance
– abdominal tenderness
– some superficial organs and masses
▪ Deep palpation is used to delineate abdominal masses.
▪ Use the palmar surface of the fingers, feel all four quadrants.
▪ Identify, locate and describe any masses.
▪ If difficult, e.g. due to obesity, use both hands, upper hand pushes downwards, lower hand feels for masses.
▪ Do not apply excessive force.
Abdominal Percussion
▪ Tympany
▪ Dullness over solid mass
– organs (liver)
– fluid
– solid (masses)
▪ Percuss all four quadrants lightly
Abdominal Physical Assessment
- Peritoneal irritation - Ask the patient to cough before palpation, if the cough causes pain ask where, localise pain area by palpating gently with one finger
- Rebound Tenderness - Press in slowly and firmly, release pressure quickly. Pain is felt on release of pressure
Anus and rectum
- Position in left recumbent or Sims position
- Inspection and Palpation
- Examine for lesions, cracks, nodules, distended veins (haemorrhoids), masses or polyps
- Observe for faecal mass
- Used gloved finger to palpate anus and rectum to assess sphincter tone and mucosal lining (masses, polyps, bleeding)
- Perianal inspection for skin irritation, breakdown, prolapse, fissures or fistula’s
Assessment of bowel function
- Presenting concern with bowel function
- Usual bowel pattern, stool characteristics
- History of change or disturbance
- Bowel symptoms
- Anal symptoms
- Medication
- Past history
- Health and lifestyle management
- Environmental issues
Bowel (colon) functions
▪ Large intestine primary organ of bowel elimination
▪ Absorption:
Consistency- About 800-1000ml liquid absorbed –Semi solid stool
- When absorption does not occur- Watery stool
- Stool remains too long in colon- Stool dry and hard
▪ Manufacture of certain vitamins
- especially vitamin K and biotin (a B vitamin), for absorption into the blood.
▪ Formation of faeces
▪ Expulsion of faeces
Normal Characteristics of faeces
Colour
▪ Infant
- yellow to brown
▪ Adult
- Normal brown (bile pigment)
- Stool black- if red meat and dark green vegetables eaten
- Light brown stool- diet high in milk products
▪ Odour
- pungent , affected by food ingested
▪ Shape
- tubular shape about 2.5 cm in diameter
▪ Flatus
- 400 to 700 ml daily
Abnormal characteristics of stool
▪ Change in bowel habit
▪ Colour
-Black/tarry – malaena, stool/iron ingestion/bleeding
-Reddish - fresh blood, lower G.I. bleeding, haemorrhoids
-Clay - absence of bile
-Pale with fat – malabsorption
- Medications may affect stool colour
▪ Consistency
- loose, compact, pathological conditions influence consistency
▪ Odour
-Excessive fermentation causes strong odour
-Blood causes a unique odour
▪ Flatus
– bacterial overgrowth can cause result in bloating, flatulence, abdominal and/or gas pain discomfort and diarrhoea.
