Nursing Assessment: Gastrointestinal System

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Nursing Assessment Gastrointestinal System

• George Ann Daniels, MS, RN

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Common assessment Abnormalities

• Mouth
• Ulcer, plaque on lips or in mouth
• Cheilosis
• Fissuring/cracking of lips at angles of the mouth
• Riboflavin deficiency
• Leukoplakia
• Thicken white patches
• Pre-malignant lesion

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• Herpes simplex
• Benign vesicular lesions
• Candidiasis
• White curdlike lesions surrounded by
  erythematorus mucosa
• yeast

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• Glossitis
• Reddened, ulcerated swollen tongue
• Vit B deficiency, irritation, injury, exposure to
  streptococci

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Esophagus and Stomach

• Dysphagia
• Difficulty swallowing
• Sensation of food sticking in the esophagus
• Hematemesis
• Vomiting of blood
• Pyrosis
• Heartburn
• Dyspepsia
• Burning pain

• Eructation
• Belching
• Nausea/Vomiting
• Feeling of or expulsion of gastric contents
  through the mouth

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Abdomen

• Distention
• Enlarged abdomen
• Excessive gas accumulation
• Tympany
• Ascities
• Accumulation of fluid within the abdominal cavity
• Bruit
• Humming or swishing sound heard through
  stethoscope over vessels
• Narrowing of the vessels

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• Boyborygmi
• Waves of loud, gurgling sound
• Hyperactive bowel
• Rebound tenderness
• Sudden pain when fingers are withdrawn quickly
• Appendicitis

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• Hernia
• Bulge or nodule in abdomen
• Appearing on straining
• Inguinal, femoral, umbilical, or incisional

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Rectum and Anus

• Hemorrhoids
• Thrombosed veins in rectum and anus
• Internal or external
• Tenesmus
• Painful and ineffective straining at stool
• Steatorrhea
• Fatty, frothy, foul smelling stool
• Floaters

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Manifestations of GI Dysfunction

• Anorexia
• Absence of the desire to eat
• Weight, dull,thin brittle hair, tired, apathetic
  facial expression dry skin and nails muscle
  wasting
• Lab work-malnutrition
• Albumin
• Lymphocyte count
• Changes in electrolytes
• NDX
• Altered Nutrition
• Altered health maintenance

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• Intestinal gas
• Flatus is gas passed through the rectum
• Swallowed air, or gas forming foods
• 0.6 L is passed daily

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• Bleeding
• Upper or lower GI tract
• Acute- 1000mL or discrete of 100mL
• Chronic over a period of weeks or months
• Types
• Occult
• Melena
• Hematochezia
• Retorrhagia
• Hematemesis

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• Management
• Assess blood loss
• VS
• Systolic B/P
• HR
• HCT/HGB
• IV NS/LR
• Transfusion
• TX varies with diagnosis

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Diagnostic Procedures

• Gastric Analysis
• Stomach contents are examined
• Hydrochloric Acid
• Occult Blood
• Malignant cells
• Bacteria
• Parasites
• Preparation
• Light meal or clear liquids night before
• NPO after midnight
• No smoking the morning of test
• N/G tube
• Complications- N/V

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• Upper GI series/Barium Swallow
• Esophagus, stomach, and duodenum bulb
• Preparation
• NPO after midnight 8-12 hours
• No smoking after midnight
• Upright position behind fluoroscopic screen
• Swallow Barium Contrast medium
• Various positions by tilt table
• Visualize barium passing through GI tract
• 1-2 hours
• Post procedure encourage fluids
• Constipation may occur from barium
• White stools up to 72 hours
• Increase fluids
• Laxative-MOM
• Elderly consideration
• Tolerance of prep

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Barium Enema/ Lower GI

• Examination of rectum and colon
• Tumors, polyps, diverticula, filling defects
  associated with Crohns and ulcerative colitis.
• Preparation
• Bowel prep
• Day before
• Tape water enemas till clear
• Oral cathartic
• GoLytely
• Clear Liquid evening meal
• NPO 8 hours

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• Day of procedure
• Suppository or enema
• Barium instilled into large intestines through
  the rectum
• patient is placed in different positions
• patient then expels barium, further pictures are
  taken
• Cramps and urge to defecate
• Post
• Oral cathartic, oil retention enema, laxative,
  suppository
• Remove residual barium
• Stools will be white

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• Oral Cholecystogram
• Visualization of GB for GB disease /stones
• 1 hour
• Allergy to iodine and shelfish
• Preparation
• Fat free diet night before
• Ingestion of radiopaque dye tablets at 7 PM
• Calculation is based on body weight of client
• NPO after midnight
• May take two days of dye

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• Day of procedure
• Films are taken
• If gallstones are seen the fatty diet is held
• Fatty diet given
• Stimulation of GB
• Further films are taken
• Complication
• Diarrhea and vomiting Allergy to iodine

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Endoscopy

• Visualization of the Upper and lower GI tract by
  fiberopitc tube
• EGD
• Esophagogastroduodenoscopy
• Esophagus, stomach, duodenum
• Fiberoptic tube passing through the mouth

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• Hiatus hernia, esophageal varcies, esophagitis,
  ulcer disease, polyps, strictures, malignant
  tumors, biopsy specimens

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• Preparation
• NPO for 8 hours
• Consent
• Sedative for anxiety
• Versed, diaxapam
• Patient will be sedated during procedure
• Throat anesthetized with oral anesthetic
• Diminished gag reflex
• Lateral recumbent position
• Instructed to swallow as tube is advanced
• Must lie still during procedure
• Post procedure
• NPO until gag reflex returns
• Assess for return of gag reflex (1-2 H)

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• Vital signs including temperature
• Q 15-30 minutes for 1-2 hours
• Sudden spike in temperature may indicate
  perforation
• Complication
• Aspiration, bleeding from trauma, infection, and
  pain
• Sore throat
• Warm saline gargle

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Colonoscopy

• Visualization of the large intestines to the
  ileocecal value by fiberoptic tube via rectum
• Undiagnosed constipation/diarrhea, anorexia,
  persistent rectal bleeding, lower abd pain,
  recurring polyps and tumors.

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• Preparation
• NPO- 8 hours
• Laxative for 1-3 days prior
• Night before enema
• Golyte
• 8 0z Q 10 minutes
• Morning of
• Clear liquids
• Procedure
• Sedative ( Valium)
• Left sims

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• Post procedure
• Cramps
• Due to inflation of colon with air
• Vital signs
• Observe for rectal bleeding, abdominal
  distention, Tenesmus