Gastro-Intestinal System

Assessment
❖​ Outlines:

Health history:

●​ Personal data

●​ Medical History

●​ History of Medications: Past and current medication

●​ Assessment of nutritional status:

●​ Present history

Physical assessment:

A.​ Inspection.

B.​ Auscultation.

C.​ Percussion

D.​ Palpation.
Health history:

Personal data:

●​ Age, sex, marital status, level of education, occupation, date of admission,

diagnosis....... etc

Medical History

●​ Previous hospitalization

●​ Past history of gastrointestinal problems: stomatitis, bleeding ulcer, gallbladder

disease, liver diseases, jaundice, appendicitis, colitis, abdominal hernia.... etc

●​ Associated diseases as: Diabetes Mellitus, kidney diseases...etc

●​ Allergies from medication, dye, food, irritant agents or insects.

●​ Previous trauma or injuries, congenital anomalies.

●​ Pervious abdominal diagnostic studies as x ray, Computed tomography

History of Medications: Past and current medication

Names of medication (prescribed or over the counter), Dose, frequency

Example: Non-steroidal anti-inflammatory drugs (NSAIDs): hepatotoxic and predispose

to upper GIT bleeding.

Anti-biotic: have the potential to change the normal bacterial composition in the GIT tract
resulting in diarrhea.

Assessment of nutritional status:

-​ Food pattern: day dairy, characteristic of healthy food

-​ Problem related to food intake (Loss of appetite, polymia, anorexia, nausea,

vomiting)

-​ Nutritional habit: Number of meals\day

-​ Likes & dislikes, Amount of fluid intake \day.

-​ Dietary intake (fats; salt, carbohydrates).

-​ Body mass index by assess patient's height and weight

-​ Assessment for obesity.

 -​ Laboratory test results (blood glucose level, hemoglobin, cholesterol, triglyceride
level....etc)

Elimination:

●​ Assess bowel habits and note the frequency, time of usual defecation, consistency of
stool, color and odor

●​ Abdominal distention, Constipation, Diarrhea

●​ Use of laxatives: Which ones? How often do you use them?

Present health history:

●​ Reason for hospitalization

●​ Patient's complains; pain, indigestion& heart burn, nausea, vomiting. .etc

Abdominal pain:

Pain can be a major symptom of GI disease; in particular, abdominal pain is a

frequent presenting problem

Assess the abdomen pain by COLDSPA-

-Character: cramping (colic type), burning, dull, stabbing, aching tightness, sharp or
squeezing

-Onset: sudden or gradually

-Location: according nine abdominal regions

-Duration: Frequency/day.

-Severity: mild, moderate or severe.

-Radiation: Arms, neck, jaw, Shoulders or back.

-Precipitating factors: Exertion, Stress, Smoking, Meals,position,, medication and activity.

-Alleviating factors: Rest or medication, heating pad, change in position.

-Associated manifestations: fatigue, nausea, vomiting, fever, rectal bleeding, change

bowel habit.
 Common sites of referred abdominal pain

Nausea: Nausea:

Is a vague, uncomfortable sensation of sickness and may or may not be followed by

vomiting. Distention of the duodenum or upper intestinal tract is a common cause

Nausea can be triggered by odors, activity, food intake, odor and medication

●​ How often comes up?

●​ Is the nausea and vomiting associated with colicky pain, diarrhea, fever, chills?

●​ Which types of food causes nausea or vomiting?

Vomiting is the forceful emptying of the stomach and intestinal contents through the mouth

●​ Assess for amount, consistency, odor, Color: bloody or not, Frequency/day:

●​ Aggravating factors, associated manifestations: colicky pain, diarrhea, fever and

chills.

●​ Relieving factors: rest or medication

Food intolerance:

●​ Are there any foods you cannot eat? What happens if you eat them: allergic reaction,
heartburn, belching, bloating and indigestion"

●​ Do you use antacids? How often?

●​ Use of antacids? How often?

-Dysphagia:

●​ Any difficulty of swallowing? When did you first notice this

Dyspepsia

Difficulty in digestion or upper abdominal discomfort associated with eating (commonly

called indigestion) is the most common symptom of patients with GI

dysfunction. And manifested by epigastric symptoms such as pain, discomfort, fullness,

bloating early satiety, heartburn, or regurgitation

Change in Bowel Habits and Stool Characteristics

Changes in bowel habits may signal colonic dysfunction or disease..

Diarrhea an abnormal increase in the frequency and liquidity of the stool commonly occurs
when the contents move so rapidly through the intestine and colon that there is inadequate
time for the GI secretions and oral contents to be absorbed. This physiologic function is
typically associated with abdominal pain or cramping and nausea or vomiting.

Constipation a decrease in the frequency of stool, or stools that are hard, dry and of smaller
volume than typical-may be associated with anal discomfort and rectal bleeding, and is a
frequent reason patients seek health care referrals

Physical examination:

Patient's preparation:

●​ Explain the procedure to the patient, which body parts will be examined and the
assessment should not be painful.

●​ Ask the patient to wear a gown.

●​ Ask the patient to empty the bladder before the examination to be more comfortable
during the assessment and to facilitate assessment of abdomen..

●​ Choose assessment time as the patient is free from pain as possible. Not interfere
with meals, daily routines, treatment, or visiting hours.

Environmental preparation:

●​ Clean, well ventilated, quiet, comfortable temperature of the room.

●​ Use good lighting

●​ Excuse the visitors.

Preparation of equipment:

Stethoscope, Small centimeter ruler, Skin-marking pen, Alcohol swab and sheet to cover
lower half

Techniques used for abdominal examination:

●​ Inspection.

●​ Auscultation.

●​ Percussion.

●​ Palpation.

Inspection:

General appearance:

●​ Assess of facial expression for pain, discomfort, anxiety...etc

●​ Inspect face for discoloration (yellowish for jaundice, pale in case of anemia)

●​ Inspect eye lid for presence of Xanthelasma (symmetrical yellow plaques around the
eyelids) may be present in primary biliary cirrhosis or chronic biliary obstruction.

●​ Look for spider naevi present in (liver disease)

●​ Inspect mouth for angular stomatitis (which may be due to iron deficiency), signs of
dehydration, ulcers.

●​ Examination of neck by palpate the supraclavicular fossa: Troisier's sign is

supraclavicular lymphadenopathy due to metastatic thoracic or abdominal
malignancy.

●​ Inspect hand for: finger clubbing: may occur with ulcerative colitis, Crohn's disease,
or other mal-absorption syndromes.

●​ Palmar erythema: a sign of liver dysfunction.

Abdomen

The abdomen constitutes the part of the body between the thorax (chest) and pelvis.

The region occupied by the abdomen is termed the abdominal cavity. The boundary of the
abdominal cavity is the abdominal wall
The abdomen contains all the digestive organs, including the stomach, small and large
intestines, pancreas, liver kidneys, spleen and gallbladder. These organs are held together
loosely by connecting tissues that allow them to expand and to slide against each other.

The abdomen also contains the important blood vessels including the aorta and inferior vena
cava.

Abdominal regions

The most common and widely accepted system for identification of the various regions of the
abdomen is the simple division of the abdomen into 4 quadrants by a vertical and horizontal
line bisecting the umbilicus into the right and left upper and lower quadrants.
 Right Upper Quadrant Left Upper Quadrant

●​ Liver ●​ Stomach

●​ Gallbladder ●​ Spleen

●​ Duodenum ●​ Left lobe of liver

●​ Head of pancreas ●​ Body of pancreas

●​ Right kidney and adrenal ●​ Left kidney and adrenal

●​ Hepatic flexure of colon ●​ Splenic flexure of colon

●​ Part of ascending and transverse ●​ Part of transverse descending colon

colon and descending colon

Right Lower Quadrant Left Lower Quadrant

●​ Cecum ●​ Part of descending colon

●​ Appendix ●​ Sigmoid colon

●​ Right ovary and tube ●​ Left ovary and tube

●​ Right ureter ●​ Left ureter

●​ Right spermatic cord ●​ Left spermatic cord

Midline

●​ Aorta

●​ Uterus (if enlarged)

●​ Bladder (if distended)

Also another division of the abdomen is nine abdominal regions

Skin of abdomen:

●​ The skin is smooth and even, with homogeneous color. no lesions are present

●​ Veins usually are not seen, but a fine venous network may be visible in thin persons

●​ Good skin turgor reflects healthy nutrition. Gently pinch up a fold of skin, then release
to note the skin's immediate return to original position.

Abnormal finding:

●​ Redness with localize inflammation.

●​ Yellowish skin.

●​ Skin glistening and taut with ascites.

●​ Striae which is silvery white, linear marks about 1 to 6 cm long. It occur when elastic
fibers of the skin are broken following rapid or prolonged stretching, as in pregnancy
or excessive weight gain and ascite. Recent striae are pink or blue and then they turn
silvery white.

●​ Striae look purple-blue with Cushing's syndrome (excess adrenocortical hormone the
skin to be fragile and broken from normal stretching)

●​ Petechiae.

●​ Cutaneous angiomas (spider nevi) occur with portal hypertension, Lesions, rashes,
surgical scar
 ●​ Poor turgor occurs with dehydration, which often accompanies gastrointestinal
diseases.

Contour or shape of the abdomen

Normal shape (flat, rounded)

Abnormal finding in Abdomen Contour:

(Scaphoid abdomen, Protuberant abdomen, abdominal distention)

Symmetry of abdomen:

The abdomen should be symmetric bilaterally.

Abnormal Finding

●​ Bulging or visible masses may notice.

●​ Hernia: (protrusion of abdominal viscera through abnormal opening in muscle wall).

●​ Enlarged liver or spleen.

Umbilicus:

Normally it is midline and inverted, with no sign of discoloration, inflammation, or hernia. It

becomes everted and pushed upward with pregnancy.

Abnormal Finding:

●​ Everted in ascites or underlying mass.

●​ Deeply sunken in obesity.

●​ Enlarged and everted in umbilical hernia.

 ●​ Bluish color occurs with intra-abdominal bleeding.

Pulsation or Movement of abdomen:

Pulsation from the abdominal aorta beneath the skin in the epigastric area may be seen
particularly in thin persons with good muscle wall relaxation.

Respiratory movement also may show in the abdomen. Waves of peristalsis sometimes are
visible in very thin persons.

Abnormal Finding:

Marked pulsation of aorta occurs with (hypertension, aortic insufficiency,).

Marked visible peristalsis, together with a distended abdomen, may show in severe diarrhea.

Demeanor:

A comfortable person is relaxed quietly on the examining table and has a benign facial
expression and slow, even respirations.

Abnormal Finding:

●​ Restlessness and constant turning to find a comfortable position occur with the
colicky pain of gastroenteritis or bowel obstruction.

●​ Absolute stillness, resisting any movement, occurs with the pain of peritonitis.

Auscultation:

This is done before percussion and palpation because they can increase peristalsis, which
would give a false interpretation of bowel sounds

Auscultate bowel sounds:

Bowel sounds originate from the movement of air and fluid through the small intestine. Bowel
sounds are high pitched, gurgling, cascading sounds from 5 to 30 times per minute

●​ Use the diaphragm of the stethoscope to listen to pitched sounds, press the
diaphragm firmly on the body part being auscultate in 4 quadrants

●​ Hold the stethoscope lightly against the skin; pushing too hard may stimulate more
bowel sounds.

●​ Note the character and frequency of bowel sounds...

Abnormal Finding in Bowel Sounds

Hyperactive: sounds are loud, high-pitched, rushing sounds that signal increased motility.

Hypoactive follow abdominal surgery or with inflammation of the peritoneum

Absent. In case of intestinal obstruction

Percussion:

This technique is performed by tapping the patient's skin with short sharp strokes to assess
underlying structures. The strokes yield a palpable vibration & a characteristic sound that
depicts the local size and density

-​ Percuss to assess the relative density of abdominal contents, to locate organs and to
screen for abnormal fluid or masses.

General Tympany:

Percuss lightly in all four quadrants to determine the prevailing amount of tympany and
dullness. Tympany should predominate because air in the intestines rises to the surface
when the person is supine.

Abnormal Finding

Dullness occurs over distended bladder, adipose tissue, fluid, or a mass Hyper -

resonance: is present with gaseous distention.

Liver Span:

Percuss to map out the boundaries of liver.

●​ Determine midclavicular line landmark, by palpating the acromioclavicular and the

sternoclavicular joints and judge the line at a point midway between the two.

●​ Measure the height of the liver in the right mid-clavicular line.

●​ Begin in the area of lung resonance, and percuss down the interspaces until the
sound changes to a dull quality.

●​ Mark the spot, usually in the fifth intercostal space.

●​ Then find abdominal tympany and percuss up in the midclavicular line.

●​ Mark where the sound changes from tympany to a dull sound, normally at the right
costal margin.
 ●​ Measure the distance between the two marks; the normal liver span in the adult
ranges from 6 to 12 cm.

●​ The height of the liver span correlates with the height of the person; taller people
have longer livers. The mean liver 10.5 cm for males and 7 cm for females.

Abnormal Finding in Liver Span

i. An enlarged liver span indicates liver enlargement or hepatomegaly.

ii. Accurate detection of liver borders is confused by dullness above the fifth intercostal
space, which occurs with lung disease, e.g., pleural effusion.

iii. Accurate detection at the lower border is confused when dullness is pushed up with
ascites or pregnancy or with gas distention in colon, which obscures lower border.

Splenic Dullness:

●​ Often the spleen is obscured by stomach contents; it locates by percussing for a dull
note from the 9th to 11th intercostal space just behind the left mid-axillary line.

●​ The area of splenic dullness normally is not wider than 7 cm in the adult.
Special Procedures:

At times, when the patient has ascites (free fluid in the peritoneal cavity) because of a
distended abdomen, bulging flanks and an umbilicus that is protruding and

displaced downward. The nurse can differentiate ascites from gascous distention by
performing two percussion tests:

A.​ Fluid Wave

It is a test for a fluid wave by standing on the person's right side.

●​ Place the ulnar edge of another examiner's hand or the patient's own hand firmly on
the abdomen in the midline.

●​ Place your left hand on the person's right flank.

●​ With your right hand, reach across the abdomen and give the left flank a firm strike:

●​ If ascites is present, the blow will generate a fluid wave through the abdomen and
you will feel a distinct tap on your left hand.

●​ If the abdomen is distended from gas or adipose tissue, you will feel no change.

●​ Ascites occurs with heart failure, portal hypertension, cirrhosis, hepatitis and
pancreatitis.

●​ A positive fluid wave test occurs with large amounts of ascitic fluid.
 B.​ Shifting Dullness:

The second test for ascites is percussing for shifting dullness.

In a supine person, ascetic fluid settles by gravity into the flanks, displacing the air-filled
bowel upward.

●​ The nurse will hear a tympany sound as you percuss over the top of the abdomen
because gas-filled intestines float over the fluid. Then percuss down the side of the
abdomen.

●​ If fluid is present, the note will change from tympany to dull as you reach its level.
Mark this spot.

●​ Now turn the person onto the right side

●​ The fluid will gravitate to the dependent (in this case, right) side, displacing the lighter
bowel upward.

●​ Begin percussing the upper side of the abdomen and move downward.

●​ The sound changes from tympany to a dull sound as you reach the fluid level, but
this time the level of dullness is higher, upward the umbilicus.

●​ This shifting level of dullness indicates the presence of fluid.

●​ Shifting dullness is positive with a large volume of ascitic fluid: It will not detect less
than 500 ml of fluid.
Palpation of abdomen

This technique used to determine textures, temperature, moisture, size, location,

consistency of certain organs, swelling, vibration or pulsation and to screen for an abnormal
mass or tenderness

Ask the patient to bend his knees.

Keep your palpating hand low and parallel to the abdomen.

Ask the patient to breathe slowly (through the nose and out through the mouth)

●​ Move both hands around as you palpate;.

Abnormal finding

●​ Guarding

●​ Tenderness

●​ Distention (soft, firm).

●​ Pain (location, characteristics).

For light palpation:

Apply light pressure with the fingers together depressing the skin & underlying structures
about ½ inch (1 cm).this give an impression of the skin surface and superficial musculature

Begin with light palpation. With the first four fingers close together, depress the skin about 1
cm.

Make a gentle rotary motion, sliding the fingers and skin together.

Then lift the fingers (do not drag them) and move clockwise to the next location around the
abdomen.

Abnormal Finding in light palpation:

●​ Muscle guarding.

●​ Involuntary rigidity is a constant board like hardness muscles accompanying acute

inflammation of the peritoneum and may be unilateral.

●​ Large masses.
 ●​ Tenderness.

N.B: Voluntary guarding occurs when the person is cold, tense, or ticklish. It is bilateral and
the muscles relax slightly during exhalation. If the rigidity persists, it is probably involuntary
guarding.

For deep palpation:

Deep palpation carries a risk of possible internal injury so it should be used cautiously and
only after considerable practice.

●​ Place the two hands on top of each other and push down about 5 to 8 cm. The top
hand does the pushing; the bottom hand is relaxed and can concentrate on the
sense of palpation.

●​ Note the location, size, consistency and mobility of any palpable organs and the
presence of any abnormal enlargement, tenderness, or masses.

●​ Tenderness normally is present when palpating the sigmoid colon. Any other
tenderness should be investigated.

Abnormal Finding in Deep Palpation:

●​ Tenderness occurs with local inflammation of the peritoneum or underlying organ and
with an enlarged organ whose capsule is stretched.

If any masses felt, first distinguish it from a normally palpable structure or an enlarged organ.
Then note its:

●​ Location and Size

●​ Consistency: (soft. firm. hard)

●​ Surface (Smooth. Nodula)

●​ Mobility (including movement with respiration, Pulsation and Tenderness0.

Obturator Test:

The obturator test also is performed when appendicitis is suspected.

With the person supine, lift the right leg, flexing at the hip and 90 degrees at the knee. Hold
the ankle and rotate the leg internally and externally.

●​ A negative or normal response is no pain

Abnormal Finding in Obturator Test

A perforated appendix irritates the obturator muscle, producing pain.

Laboratory tests

●​ Fecal occult blood test. It involves placing a very small amount of stool on a special
card. The stool is then tested for hidden (occult) blood in the stool.

Patient preparation:

Various foods, dietary supplements and medications can affect the results of the test

-​ either indicating that blood is present. To ensure accurate test results, follow
instructions carefully:

1.​ For about three days before the test, ask the patient to avoid:

●​ Certain fruits and vegetables, including turnips, broccoli, horseradish, cauliflower,

rock melon, parsnip and radishes

●​ Red meat

●​ Chocolate

●​ Vitamin C supplements

●​ Pain relievers, such as aspirin and ibuprofen (Advil, Motrin IB, others)

2.​ Women should not collect a specimen during their menstrual cycle.

Stool culture.

A stool culture checks for the presence of abnormal bacteria in the digestive tract.

Patient preparation:

-​ Inform the patient to stop any antibiotic taken three days before the test.