Instit16health2.pdfghujjjgjkkggikjhgghhhjj

Nursing Assessment of the
Gastrointestinal System

Function
of the
Gastro-intestinal System

A. Ingestion ( Taking In Food)
B. Digestion ( Breakdown of Food)
C. Absorption ( transfer of food products into the
circulation)
D. Elimination :is the process of excreting the
waste products of digestion.

Structures and Functions
The gastrointestinal ( GI) System consists of the GI tract and its
associated organs and glands
A. GI tract
1. mouth
2. esophagus
3. stomach
4. small intestine
5. large intestine
6. rectum
7. anus
B. Associated organs
1. liver
2. gall bladder
3. pancreas

 The stomach
 The stomach can divided into four anatomic
regions:
 1- Cardiac (entrance)
 2- Fundus
 3- Body
 4- Pylorus (outlet)

Small Intestine
 The small intestine is a coiled tube
approximately (7 m) in length and (2.5 to
2.8 cm) in diameter.
 It extends from the pylorus to the ileocecal
valve. The small intestine is composed of
the duodenum, jejunum, and ileum.

 The ileocecal valve prevents reflux of large
intestine contents into the small intestine.
 The two primary functions of the small
intestine are digestion and absorption
(uptake of nutrients from the gut lumen to
the bloodstream)

Large intestines
 The large intestine is a hollow, muscular
tube approximately (1.5 to 1.8 m) long and
(5 cm) in diameter. it consists of an
ascending segment on the right side of the
abdomen , a transverse segment that extend
from right to left in the upper abdomen and
descending segment on the left side of the
abdomen.


 * The terminal portion of the large intestine
consists of two parts: the sigmoid colon and the
rectum, the rectum is continues with the anus.

Associated Organs of the GI
System

Liver, Biliary Tract, and Pancreas
Liver.
 The liver is the largest internal organ in the
body, weighing approximately (1.36 kg). It
lies in the right epigastric region.

Pancreas.
 The pancreas has both exocrine and endocrine
functions.
 The exocrine function contributes to digestion
through the production and release of enzymes
 The endocrine function occurs in the islets of
Langerhans, whose β cells secrete insulin and
amylin.

 The gallbladder:
 Located below the liver
 The cystic duct joins the hepatic duct
to become the bile duct
 The common bile duct joins the
pancreatic duct in the sphincter of
Oddi in the first part of the
duodenum

1-Health history:
-Past Health History. Subjective Data
Gather information from the patient about the
history or existence of the following problems
related to GI functioning:
 abdominal pain, nausea and vomiting, diarrhea,
constipation, abdominal distention, jaundice,
anemia, heartburn, dyspepsia, changes in
appetite, hematemsis, food intolerance or
allergies, indigestion, excessive gas, lactose
intolerance, melena, trouble swallowing,
hemorrhoids, or rectal bleeding

 History or existence of diseases such as reflux,
gastritis, hepatitis, colitis, gallstones, peptic ulcer,
cancer, diverticuli, or hernias.
 Question the patient about weight history.
 Explore in detail any unexplained or unplanned
weight loss or gain within the past 6 to 12 months.

Past History of Medications.
 The names of all drugs, frequency of use, and
their duration of use are important because
many medications may not only have an effect on
the GI system but also may be affected by
abnormalities of the GI system.
For example, chronic high doses of acetaminophen
and non steroidal anti-inflammatory drugs
(NSAIDs) may be hepatotoxic.

 Past History for Surgery or Other Treatments.
Hospitalization for any problem related to the GI
system. As abdominal or rectal surgery,
information including the year, reason for
surgery, postoperative course.
 Assess Functional Health Patterns.
Key questions to ask a patient with a GI problem
such as:

Questions related to Nutrition-Metabolism
 Describe usual daily food and fluid intake.
 Do you take any supplemental vitamins or
minerals?*
 Have you experienced any changes in appetite or
food tolerance?*
 Has there been a weight change in the past 6-12
months?*
 Are you allergic to any food?*

Questions related to Elimination
 Describe the frequency and time of day for bowel
movements.
 What is the consistency of stool?
 Do you use laxatives or enemas?* If so, how
often?
 Have there been any recent changes in your
bowel pattern?*
 Do you need any assistive equipment, such as
ostomy equipment, raised toilet seat, commode?

Questions related to Activity-Exercise
 Do you have limitations in mobility that make it
difficult for you to prepare food?*
Questions related to Sleep-Rest
 Do you experience any difficulty sleeping
because of a GI problem?*
 Are you awakened by symptoms such as gas,
abdominal pain, diarrhea, or heartburn?*

2-Common symptoms related to GIT disorders
Pain
 Pain can be a major symptom of gastrointestinal diseases
 The character, duration, pattern, frequency and time of
pain depending on the underlying cause of pain which
also affect the location and distribution of the referred
pain.
 Other factors such as meals, rest, defecation and
vascular disorders may directly affect this pain

Intestinal gas (belching and flatulence)
 The accumulation of gas in G I T may result in
belching (the releasing gas from the stomach
through mouth)
 Flatulence (releasing gas from the digestive
system through the anus).

Nausea and vomiting
 The involuntary act of vomiting is another major
symptom of G I disease.
 vomiting is usually preceded by nausea which
can be triggered by odors, activity, and food
intake.

Change in bowel habits and characteristics
* Diarrhea
 An abnormal increase in frequency and liquidity of
stool and in the daily stool volume.
 Diarrhea commonly occurs when the contents move so
rabidly through the intestine and colon that there is
inadequate time for G I secretion to be absorbed.
 Diarrhea is some times associated with abdominal
cramping nausea and vomiting.

* Constipation
 It is the retention or a delay in expulsion of fecal from
the rectum may be associated with anal discomfort or
rectal bleeding.
 Excess water is absorbed from the fecal matter produce
hard dry and smaller volume than normal

Physical Examination
(Objective Data)

Inspection
 Mouth
Lips
should be symmetrical, pink, smooth and moist.
There should be no growths, lumps or
discoloration of the tissue.

Abnormal Findings
 If the lips are asymmetrical, cyanotic, cherry red,
pale or dry.
 Lips disorders :
Aphthous ulcer, Angular stomatitis,
Carcinoma, Cleft lip,
Leukoplakia, Herpes simplex and Chelitis

Teeth
"The condition of the teeth should be clean with no
decay, appear white and shiny enamel with
smooth surfaces and edges.
Abnormal findings
 Missing teeth, loose or broken teeth and
misaligned teeth
 Teeth disorders : Decay, Epulis, Meth
Mouth, Hutchinson's teeth

 Gums
 The gums should appear symmetrical, moist,
pink with tight well defined margins.
 Abnormal Findings
 Include swelling, cyanotic, pale, dry, spongy
texture, bleeding, or discolored gums.
 Diseases of the Gums: Leukoplakia,
Hyperplasia, Gingivitis, Periodontitis and
Aphthous ulcer

Hyperplasia Aphthous ulcer Leukoplakia

 Hard Palate
The palate should appear whitish in color with a firm
texture and irregular transverse rugae.
Abnormal Findings
 The palate looking yellow or showing extreme pallor.
Diseases of the Hard Palate
 Torus palatinus, Cleft palate, Kaposi's
sarcoma and Leukoplakia

Torus palatinus Kaposi's sarcoma

 Tongue
 The tongue should be pink, moist with a
slightly rough surface from the papillae. Also,
present may be a thin, whitish coating on the
tongue
Abnormal Findings
 Includes markedly reddened, cyanotic or
extreme pallor
Diseases of the Tongue ,

Migratory glossitis
(geographical tongue)
Atrophic glossitis
Candidiasis

 Rectum and Anus
 Inspect perianal and anal areas for color,
texture, masses, rashes, scars, erythema,
fissures, and external hemorrhoids.

The abdomen
1- Inspection
 The abdominal contour and symmetry of the
abdomen are noted with the identification of
localized bulging, distention or peristaltic
waves

II- Auscultation
 Auscultation is performed prior to percussion and
palpation
The intestinal sounds (bowel sounds).
 The nurse assesses bowel sounds in all four quadrants. It
is important to document the frequency of the sounds
 normal (sounds heard about every 5 to 20 seconds)

Abnormal findings as following
 Hypoactive (one or two sounds in 2 minutes),
 Hyperactive (5 to 6 sounds heard in less than 30
seconds)
 Absent (no sounds in 3 to 5 minutes).

III- Percussion
Bowel waves
 The character, location and frequency of bowel waves
are noted during percussion
 The nurse notes tympanic or dullness during percussion.
A dull sound is heard over solid organ (such as liver) a
stool filled colon, abdominal masses.
 A tympanic sound is heard over air, as in the gastric
bubble or air filled intestine.
Liver and spleen
 The size of the liver is determined by percussing .

IV- Palpation
 Light palpation used to identify abdominal
masses or areas of tenderness, swelling and note
the location, size for liver and spleen .

 Deep abdominal palpation is the two-hand
method. Place one hand on top of the other and
apply pressure to the bottom hand with the
fingers of the top hand. With the fingers of the
bottom hand, feel for organs and masses

ASSESSMENT
of
 ABNORMALITIES

Finding Description Possible Etiology
and Significance
1 Esophagus and Stomach
1-Dysphagia 1-Difficulty swallowing, sensation of
food sticking in esophagus
1-Esophageal problems,
cancer of esophagus
2-Hematemesis Vomiting of blood Esophageal varices,
bleeding peptic ulcer
3-Pyrosis Heartburn, burning in epigastric or
substernal area
Hiatal hernia,
esophagitis, -
Incompetent lower
esophageal
sphincter
4- Dyspepsia Burning or indigestion Peptic ulcer disease,
gallbladder disease
5- Nausea and
vomiting
Feeling of impending vomiting,
expulsion of gastric contents
through mouth
GI infections, common
manifestation of
many GI
diseases; stress, fear, and
pathologic conditions
6-Odynophagia Painful swallowing Cancer of esophagus,
esophagitis

Finding Description Possible Etiology and
Significance
2 Abdomen
1- Distention Excessive gas accumulation, enlarged
abdomen, generalized tympany
Obstruction, paralytic ileus
2- Ascites Accumulated fluid within abdominal
cavity, eversion of umbilicus
(usually)
Peritoneal inflammation, heart
failure, metastatic
carcinoma, cirrhosis
3- Masses Lump on palpation Tumors, cysts
4- Nodular liver Enlarged, hard liver with irregular edge
or surface
Cirrhosis, carcinoma
5-Hepatomegaly Enlargement of liver, liver edge >1-2 cm
below costal margin
Metastatic carcinoma, hepatitis,
venous congestion
6- Splenomegaly Enlarged spleen Chronic leukemia, hemolytic
states, portal hypertension,
some infections
7- Hernia Bulge or nodule in abdomen, usually
appearing on straining
Inguinal (in inguinal canal),
femoral (in femoral canal),
umbilical (herniation of
umbilicus), or incisional
(defect
in muscles after surgery)

Finding Description Possible Etiology and
Significance
3 Rectum and Anus
1- Hemorrhoids Thrombosed veins in
rectum and anus
(internal or external)
Portal hypertension,
chronic
constipation,
prolonged
sitting or standing,
pregnancy
2- Fissure Ulceration in anal canal Straining, irritation
3- Melena Abnormal, black, tarry
stool containing
digested blood
Cancer, bleeding in
upper GI tract
from ulcers,
varices
4- Steatorrhea Fatty, frothy, foul-smelling
stool
Chronic pancreatitis,
biliary
obstruction,
malabsorption

1-Radiology
1.1- Upper gastrointestinal (GI) or barium
swallow
Description and Purpose
Fluoroscopic x-ray study using contrast
medium. Used to diagnose structural
abnormalities of esophagus, stomach, and
duodenum

Nursing Responsibility
 Explain procedure to patient, including the need to drink contrast
medium and assume various
 Positions on x-ray table.
 keep patient NPO for 8-12 hr before procedure.
 Tell patient to avoid smoking after midnight before study.
 After x-ray, take measures to prevent contrast medium impaction
(fluids, laxatives).
 Tell patient that stool may be white up to 72 hr after test.

Lower GI or barium enema
 Fluoroscopic x-ray examination of colon using contrast medium,
which is administered rectally (enema)
Before procedure:
 Administer laxatives and enemas until colon is clear of stool
evening before procedure.
 Administer clear liquid diet evening
 Keep patient NPO for 8 hr before test.
 Instruct patient about being given barium by enema.
 Explain that cramping and urge to defecate may occur during
procedure and that patient may be placed in various positions on
tilt table.

After procedure:
 Give fluids, laxatives, or suppositories to assist
in expelling barium.
 Observe stool for passage of contrast medium

Ultrasound
 Used to show the size and configuration of organ. Noninvasive
procedure uses high-frequency sound waves (ultrasound waves),
which are passed into body
 structures and recorded as they are reflected
Abdominal ultrasound
 Detects abdominal masses (tumors, cysts), biliary and liver
disease, gallstones. A conductive gel (lubricant jelly) is applied
to the skin and a transducer is placed on the area

 Instruct patient to be NPO 8-12 hr before
ultrasound.
 Food intake can cause gallbladder contraction,
resulting in suboptimal study

Computed tomography (CT)
 Noninvasive radiologic examination allows for
exposures at different depths. Detects biliary
tract, liver, and pancreatic disorders. Use of oral
and IV contrast
 medium accentuates density differences

 Explain procedure to patient.
 Determine sensitivity to iodine or shellfish
if contrast material used.

Magnetic resonance imaging (MRI)
 Noninvasive procedure using radiofrequency
waves and a magnetic field. Used to detect
hepatobiliary disease, hepatic lesions, and
sources of GI bleeding and to stage colorectal
cancer. IV contrast medium (gadolinium) may be
used.

 Explain procedure to patient.
 Contraindicated in patient with metal implants
(e.g., pacemaker) or one who is pregnant

Endoscopy
A- Esophagogastroduodenoscopy (EGD)
 Description and Purpose
 Directly visualizes mucosal lining of esophagus,
stomach, and duodenum with flexible
endoscope. Test may use video imaging to
visualize stomach motility.
 Inflammations, ulcerations, tumors, varices,
Biopsies may be taken.

Before procedure:
 Keep patient NPO for 8 hr.
 Make sure signed consent is on chart.
 Give preoperative medication if ordered.
 Explain to patient that local anesthesia may be
sprayed on throat before
 insertion of scope and that patient will be sedated
during the procedure.

After procedure:
 Keep patient NPO until gag reflex returns.
 Gently tickle back of throat to determine reflex.
 Use warm saline gargles for relief of sore throat.
 Check temperature q15-30min for 1-2 hr (sudden
temperature spike is sign of perforation.

B-Colonoscopy
 Directly visualizes entire colon up to ileocecal valve
with flexible fiberoptic scope. Patient’s position is
changed frequently during procedure to assist with
advancement of scope to cecum.
 Used to diagnose or detect inflammatory bowel disease,
polyps, tumors, and diverticulosis and dilate strictures.
Procedure allows for biopsy and removal of polyps
without laparotomy.

Before procedure:
 Bowel preparation is done. This varies depending on physician.
For example,
 patients may be kept on clear liquids 1-2 days before procedure.
 Cathartic and /or enema given the night before.
 Explain to patient that flexible scope will be inserted while
patient in side-lying position.
 Explain to patient that sedation will be given.

After procedure:
 Patient may experience abdominal cramps caused by
stimulation of peristalsis because the bowel is constantly
inflated with air during procedure.
 Observe for rectal bleeding and manifestations of
perforation (e.g., malaise, abdominal distention,
tenesmus).
 Check vital signs.

Liver Function Studies
 Liver function tests are (blood) studies that
reflect hepatic disease.
Serum bilirubin

Direct Measurement of conjugated bilirubin.
Elevated in obstructive jaundice.
 Reference interval: 0.1-0.3 mg/dL)
• Indirect Measurement of unconjugated bilirubin.
Elevated in hepatocellular and hemolytic
conditions.
 Reference interval: 0.1-1.0 mg/dL

Effects of Aging on the Gastrointestinal
Tract
A. Teeth may loosen up from the supporting gums and
bones.
A. Decreased output of the salivary glands leads to
dryness of mucous membranes and increased
susceptibility to breakdown, difficulty swallowing
and decrease stimulation of the taste buds.
A. Decreased secretion of digestive enzymes and bile –
decrease ability to digest and absorb food.
>> impaired absorption of fat and fat soluble
vitamins

D. Atrophy of gastric mucosa leads to decrease
HCl acid production.
>>decrease iron and B12 absorption – anemia
>>proliferation of bacteria – diarrhea and
infection
E. Decrease peristalsis in the large intestine, decrease
muscular tone of the intestinal wall and decrease
abdominal muscle strength – decrease sensation to
defecate and increase incidence of constipation.

Teeth may loosen up from the supporting
gums


Decreased output of the salivary gland
 Dryness of the mucous
membrane
 Difficulty swallowing
 Decrease stimulation of the
taste buds

Effects of aging on the gastrointestinal tract
Decreased secretion of digestive enzymes and
bile – decrease ability to digest and absorb
food.
Ex.
Impaired absorption of fat and fat soluble
vitamins

Effects of aging on the GI tract
> Atrophy of gastric mucosa leads to decrease
HCl acid production

Factors Influencing Fecal
Elimination:
 Diet: It is one of the most important factors
affecting
-Changes in the secretion and motility of the
alimentary canal.
-The type and amount of bacteria entering the
digestive systemwill affect the fecal
characteristics.
- Fluid intake has to do with stool consistency.

 Psychological Factors:
- In period of stress caused by fear, grief, or anger
depression, chronic psychosis, and anorexia
nervosa.) may increase or decrease muscle
spasms or peristaltic activity result Diarrhea or
constipation

 Physical Activity:
Physical activity influences elimination by
promoting the development of muscle tone as
well as by stimulating appetite and peristalsis.
 - Increased activity will stimulate the colon.
 - Immobility, changes in posture or sleep will
depress the colon.

 Neurogenic Conditions:
Neurogenic conditions of the nervous system,
such as, brain and cord tumors, and meningitis
frequently leave a person with chronic
constipation.

 Muscular Condition:
Abdominal, pelvic and diaphragmatic muscles
play an important role in initiating and
completing defection.
Any Injuries or other conditions affecting the
strength of tense muscles will therefore make
evacuation difficult.

 Drugs: e.g.
Laxatives excessive use lead to diarrhea.
constipation may caused by Certain medications,
including pain medications, diuretics and those
used to treat Parkinson's disease, high blood
pressure and depression

Common Problems of Intestinal
Elimination
 Constipation:
 The passage of unusually dry, hard stools
produced by delay in the passage of feces.
 Fecal Impaction
 A prolonged retention or an accumulation of
fecal material which forms a hardened mass in
the rectum. It may be of sufficient size to
prevent the passage of normal stool.

 Intestinal Distention (Tympanitis)
Excessive formation and accumulation of gasses in
the intestines.
 Diarrhea:
The passage of loose, watery stool and an increase
in the frequency of bowel movements.
 Feacal ( anal ) incontinence
Inability of the anal sphincter to control the
discharge of feces, i.e. loss of voluntary control
over the act of defecation.

Symptoms of Gastrointestinal
Diseases
 Pain
 Indigestion and heartburn,
 Nausea and vomiting,
 Dysphagia
 GI bleeding
 Jaundice
 Diarrhea
 Constipation

 ASSESSMENT
 History of Present Illness and Review of Systems
 General the following characteristics of each
symptom should be elicited and explored:
 Onset (sudden or gradual)
 Location
 Duration, chronology
 Characteristics/quality of symptom
 Associated symptoms

 Precipitating and aggravating factors
 Relieving factors
 Timing, frequency, and duration
 Current situation (same, improving or deteriorating)
 Previous diagnosis of similar episodes
 Previous treatments and efficacy

Sequence of Examination of the
Gastrointestinal System
Step Position
Inspection
Supine, head and knees
supported
Auscultation
Palpation
Percussion
Check for ascites Supine, may need to roll
patient for shifting dullness
Rectal examination Left lateral decubitus
Inguinal examination Standing

 Food is regurgitated
 Bowel Habits
 Last bowel movement
 Frequency, color and consistency of stool

Diagnostic Studies
A. Upper GI Series or Barrium Swallow
> X-ray study with fluoroscopy with contrast medium
> used to diagnose structural abnormalities of the
esophagus, stomach, and duodenal bulb
>NPO for 8-12 hours
> pt. will drink contrast medium
> give pt. laxatives and fluid to prevent contrast medium
impaction.
> the stool may be white up to 72 hours after the test
B. Small Bowel Series – same as upper GI series

Diagnostic tests
C. Lower GI or Barium Enema
> Fluoroscopic examination of the colon using contrast medium
w/c is administered rectally.
> administer laxatives and enemas the night before the
procedure.*****CLEAR****
> clear liquid diet the night before.
> NPO for 8 hours before the procedure.
> cramping and urge to defecate may occur.
> explain that pt will be assuming various position in tilt table.
> give laxatives, fluids to assist in expelling barium.

Diagnostic tests
C. Ultrasound
> noninvasive procedure uses high frequency soundwaves to visualize
the solid organs.
> NPO 8-12 hours
D. CT-Scan –
> non invasive radiologic examination that combines x-ray machine
and computer.
E. MRI
> non invasive procedure using radiofrequency waves and magnetic
field
> NPO for 6 hours
> C/I in pt with metal implants or who is pregnant

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