Chapter 19 Assessing the Gastrointestinal (GI) System by img20336


									                                     Chapter 19: Assessing the Gastrointestinal
                                     (GI) System

                                     What You Will Learn
                                        •	 How	to	inspect	the	oral	cavity	and	understand	the	function	of	
                                        •	 How	inspection,	auscultation,	and	palpation	of	the	abdomen	and	
                                           rectum	can	evaluate	gastrointestinal	status	in	the	elderly	patient
                                        •	 How	to	evaluate	the	patterns	and	characteristics	of	bowel		

 Author:                              Key Terms
 Sonja Albright, MSN, FNP-            Clostridium Difficile (C-diff) — A common cause of bacterial colitis
 BC, Family Nurse Practitioner,
 Sheldon Family Medical Clinic,       Ecchymosis — The escape of blood into the tissues from ruptured blood
 Sheldon, MO.                         vessels marked by a livid black and blue or purple spot on area
                                      Gastrointestinal Bleeding — Bleeding in the stomach or intestine
                                      Guarding — A sign detected during physical exam whereby the patient
                                      involuntarily contracts muscles secondary to pain
                                      Hernia — A protrusion of an organ or part through connective tissue or
                                      through a wall of the cavity in which it is normally enclosed
                                      Mass — A unified body of matter with no specific shape
                                      Oropharynx — The part of the pharynx below the soft palate and above
                                      the epiglottis and is continuous with the mouth
                                      Reflux — Movement of the stomach contents into the esophagus
                                      Rebound Tenderness — A state in which pain is felt on the release of
                                      pressure over a part, specifically, such a sensation in the abdomen; con-
                                      sidered a sign of peritonitis

Good history-taking and vital        The	gastrointestinal	(GI)	assessment	can	be	complicated.	There	are	
signs are essential to the overall   many	components	to	the	system	and	areas	to	examine.	The	GI	tract	
GI assessment.                       must	work	properly	for	both	health	and	a	feeling	of	wellness.	Eating,	
                                     swallowing,	absorption,	digestion,	and	elimination	are	all	necessary	
                                     functions	of	the	GI	system.
                                     The	components	of	a	good	GI	assessment	include	inspection,	ausculta-
                                     tion,	and	palpation.	

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                                     Begin	by	observing	the	resident’s	ability	to	chew	and	swallow	food.	
                                     Coughing	while	chewing	or	swallowing	is	abnormal	and	poses	a	chok-
                                     ing	risk.	If	food	cannot	be	chewed	into	small	enough	pieces	to	pass	easily	
Be sure to inspect the oral cavity
                                     through	the	oropharynx	and	esophagus,	it	may	cause	a	resident	to	choke.
for any lesions, masses, cavities,
or ill-fitting dentures that may     Observe	the	resident’s	dietary	intake	and	monitor	weight.	A	change	in	
interfere with chewing (see figure   weight	may	indicate	a	change	in	nutritional	status.	Changes	in	weight	may	
19.1 below).                         also	indicate	a	variety	of	other	medical	conditions	that	require	follow-up	
                                     by	the	healthcare	provider.	
                                     With	the	resident	in	a	supine	position,	inspect	the	abdomen	and	ask	about	
                                     the	resident’s	stool	pattern.	Questions	should	include:
                                        •	 Do	you	have	a	daily	bowel	movement?	If	not,	what	is	your	normal	
                                        •	 Are	you	experiencing	diarrhea	or	constipation?	
 Figure 19.1. Inspecting the Oral       •	 Do	you	have	any	difficulty	with	elimination	such	as	straining	to	
 Cavity.                                   pass	stool?	
                                        •	 Is	there	noticeable	blood	in	the	stool?	
                                        •	 Do	you	have	a	history	of	hemorrhoids?	
                                     Ask	the	resident	about	having	nausea,	heartburn,	and	GI	upset.	If	so,	do	
                                     the	symptoms	occur	before	or	after	eating?	Is	there	any	correlation	be-
                                     tween	symptom	onset	or	symptom	relief	with	food	intake.	These	specifics	
                                     will	help	the	provider	decide	which	diagnostic	tests	to	order.
F325 guidance to surveyors indi-     The	purpose	of	a	thorough	stool	assessment	is	to	help	with	problem	
cates parameters for unplanned       identification.	Stool	frequency,	consistency,	color,	and	odor	should	all	be	
and undesired weight loss (and       assessed.	If	a	resident	has	light	colored,	foul	smelling,	and	frequent	liquid	
gain) that lead to citations of:     stools,	the	provider	may	request	stool	samples	to	test	for	Clostridium dif-
 •	 One	month	–	5	percent            ficile (C-diff).	If	a	resident	complains	of	having	no	bowel	movement	for	
 •	 Three	months	–	7.5	percent       four	days	and	has	an	enlarged	abdomen,	constipation	might	be	the	prob-
 •	 Six	months	–	10	percent          lem.	Black	tarry	stools	may	be	the	result	of	oral	iron	preparations	or	upper	
                                     GI	bleeding.	Hemoccult	(stool	guaiac)	tests	for	blood	in	the	stool	are	quite	
                                     helpful	in	determining	a	diagnosis.	Blood	in	the	stool	is	always	abnormal	
Stool frequency, consistency,        and	should	be	reported	to	the	provider.	While	a	positive	result	may	only	
color, and odor should all be as-    mean	the	resident	has	an	inflamed	hemorrhoid,	it	might	also	indicate	
sessed.                              something	more	serious,	and	follow-up	by	the	provider	is	required.
                                     During	assessment	of	the	abdomen,	inspection	is	the	first	step.	Inspec-
                                     tion	of	the	abdomen	includes	observing	the	contour	and	shape.	Observe	
                                     for	symmetry	and	bulges	or	lumps	on	or	under	the	skin	surface.	If	a	bulge	
                                     is	found,	press	gently	with	flat	fingers	to	see	if	it	moves	or	flattens	(after	
                                     completing	auscultation	of	the	abdomen).	Symmetrical	distension	is	usu-
                                     ally	due	to	obesity,	but	it	can	also	indicate	fluid	retention	or	tumors.	Note	
                                     the	color	of	the	skin	around	the	umbilicus.	Ecchymosis	in	that	area	is	
                                     abnormal.	If	any	bruising	is	found	during	inspection,	inquire	about	recent	
                                     falls	or	injuries.
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                                  The	rectum	should	also	be	observed.	During	inspection,	look	for	any	bulg-
                                  ing	or	protrusion	in	the	rectal	area	that	may	suggest	impaction.	Note	any	
                                  hemorrhoids,	inflammation,	rash,	or	obvious	bleeding.	Note	any	prolapse	
                                  or	protrusions	from	the	rectum.	The	LPN	may	check	the	patient	for	fecal	
                                  impaction;	but,	providers	are	best	qualified	to	evaluate	the	patient	for	
                                  masses	to	stricture.	Any	abnormal	findings	should	be	referred	to	the	pro-
                                  vider	for	follow	up.	A	digital	rectal	exam	is	performed	only	by	a	qualified	
                                  healthcare	provider.

                                  Auscultation	of	the	abdomen	is	performed	before	palpation	to	prevent	
                                  stimulating	the	intestines.	Listen	to	all	four	quadrants	of	the	abdomen	
                                  using	the	diaphragm	of	the	stethoscope.	Normal	bowel	sounds	are	irregu-
                                  lar	and	heard	every	5-15	seconds.	With	constipation,	hypoactive	bowel	
                                  sounds	are	generally	heard.	If	no	bowel	sounds	are	heard,	try	listening	for	
If the resident is constipated,   one	to	two	minutes	just	below	and	to	the	right	of	the	umbilicus.	If	bowel	
bowel sounds are usually          sounds	are	absent,	the	provider	should	be	notified.	Loud	gurgling	bowel	
hypoactive.                       sounds	indicate	increased	peristaltic	activity.

                                  Start	with	gentle	palpation	of	the	abdomen	and	watch	for	non-verbal	signs	
                                  of	pain	as	you	move	through	the	assessment.	A	distended	abdomen,	or	
                                  any	guarding,	rigidity,	or	rebound tenderness	suggests	trouble,	and	the	
                                  provider	should	be	notified	immediately.
                                  Palpate	for	any	obvious	organ	enlargement	or	mass.	A	pulsating	mass	felt	
                                  in	the	abdomen	should	not	be	palpated	further	and	the	provider	should	
                                  be	notified	of	the	finding	immediately.	These	masses	are	usually	felt	in	the	
                                  upper	abdomen.	Sometimes,	especially	in	thin	residents,	a	mass	in	the	
                                  lower	abdomen	may	represent	fecal	material	in	the	colon.
                                  The	GI	system	presents	a	challenge	to	the	LTC	resident	and	nurse.	GI	
                                  disorders	may	lead	to	dehydration,	malnutrition,	and	weight	loss	in	older	
                                  adults.	Abdominal	pain	and	gastrointestinal	upset	can	be	caused	by	
                                  constipation,	reflux,	or	undesirable	side	effects	of	medications.	GI	disor-
                                  ders	are	often	complicated	in	the	elderly	by	the	presence	of	other	chronic	
                                  conditions	as	well	as	a	slow	and	vague	onset	of	symptoms.	Older	adults	
                                  are	less	likely	to	complain	creating	delayed	detection	of	serious	problems.	
                                  Since	the	GI	system	must	function	for	survival,	serious	impairment	in	
                                  function	is	an	emergency	and	most	often	will	result	in	immediate	hospi-
                                  talization.	Performing	a	thorough	assessment	of	the	GI	system	helps	the	
                                  nurse	recognize	and	address	concerns	early,	promoting	a	better	outcome.

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Chapter 19 Review Questions

Define the following terms:                             Answer the following multiple-choice questions:
   1.	 Clostridium	Difficile	—	                            14.	The	provider	should	be	notified	immediately	
                                                               if	the	following	is	present:
   2.	 Ecchymosis	—	                                          a.	 Light	brown	soft	stool	with	excessive	
   3.	 Gastrointestinal	Bleeding	—	                           b.	 Hypoactive	bowel	sounds
                                                              c.	 Complaints	of	discomfort	in	the	upper	
   4.	 Guarding	—	                                                abdomen	on	exam
                                                              d.	 Distension,	guarding,	rigidity,	or	rebound	
   5.	 Hernia	—	                                                  tenderness	on	exam
                                                           15.	If	a	resident	complains	of	no	bowel	move-
                                                               ment	for	four	days,	has	an	enlarged	abdomen,	
   6.	 Mass	—	
                                                               and	has	abdominal	discomfort,	the	nurse	
                                                               must	suspect:
   7.	 Oropharynx	—	                                          a.	 UTI
                                                              b.	 C-diff
   8.	 Reflux	—	
                                                              c.	 Appendicitis
                                                              d.	 Constipation
   9.	 Rebound	Tenderness	—	
                                                           16.	Normal	bowel	sounds	are	irregular	and	are	
Circle “True” or “False” as appropriate for the                heard	every:
following statements:                                         a.	 1-2	minutes
   10.	(True/False) — Guarding	is	a	term	used	to	             b.	 5-15	seconds
       describe	a	sign	detected	during	physical	exam	         c.	 1-2	seconds
       whereby	the	patient	involuntarily	contracts	
                                                              d.	 3-4	minutes
       muscles	secondary	to	pain.
   11.	(True/False) — Vital	signs	are	irrelevant	dur-
       ing	the	abdominal	exam	because	the	hands-        Complete the following:
       on	assessment	will	reveal	all	of	the	informa-
                                                           17.	List	three	abnormal	findings	the	nurse	may	
       tion	needed.
                                                               encounter	while	assessing	the	oral	cavity.
   12.	(True/False) — Assessing	stool	pattern	dur-
       ing	the	GI	assessment	is	not	necessary	unless	
       severe	abdominal	pain	is	present.                      b.
   13.	(True/False) — During	GI	assessment,		
       palpation	should	be	performed	prior	to		               c.

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Chapter 19 Review Questions, Continued

  18.	List	four	abnormal	findings	the	nurse	may	
      encounter	while	assessing	the	rectum.




  19.	Name	the	three	techniques	used	when		
      assessing	the	GI	system.



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