Gastrointestinal assessment

What position should the pt be and why?

Supine to access the abdomen and helps the abdominal muscles relax

Rationale for “PQRST”

To assess the characteristics of the pain and identify potential problems

Rationale for “Bowel movement”

To assess bowel function and look for abnormalities like constipation and diarrhoea

Rationale for “Have you experienced any nausea or vomiting”

To identify GI disturbance and assess for complications like dehydration or GI bleeding

Rationale for “In the past 24 hours, what have you been eating/drinking?”

To assess any dietary related factors affecting the pts GI functioning

What should the order of objective data be and why?

Inspection, auscultation, percussion/palpation

Percussion and palpation can stimulate bowel activity and alter bowel sounds

What do you look for in INSPECTION?

• Shape/contour

• Symmetry

• Skin

• Umbillicus

Where should you stand when inspecting the abdomen?

End of the bed

Give me the normal and abnormal findings for inspecting shape/contour

• Round or flat (normal)

• Scaphoid or distention (abnormal)

Give me normal findings for inspecting SKIN

Smooth and even with homogenous colour (same colour throughout)

Name the landmarks of the abdomen

• Costal margins

• ASIS (Anterior superior iliac spine)

• Umbillicus

• Xiphoid process

What quadrant do you start auscultating first and why?

RLQ, location of ileocaecal area where bowel sounds are best heard

Name all 9 regions of the abdomen

• Hypochondriacs

• Epigastric

• Umbillical

• Lumbars

• Hypogastric

• Iliacs

What is the normal sound to hear during percussion?

• Tympany, drum like sound

• Dullness, thud like sound

What is the purpose of light palpation?

Helps locate tenderness and assess guarding

What is the purpose of deep palpation?

Assesses tenderness and masses

Nursing diagnoses for GI assessment

• Acute pain

• Imbalanced nutrition

• Fluid volume deficit

• Altered GI function

• Constipation

Symptoms of constipation

• Hard stools

• Abdo pain

• Bloating

• Reduced bowel movements

Symptoms of imbalanced nutrition

• Poor appetite

• Weight loss

• Weakness

• Inadequate food intake

Symptoms of fluid volume deficit

• Vomiting

• Diarrhoea

• Poor fluid intake

• Fever

Why do we hear tympany when percussing?

GI contains gas

Organs in RLQ?

Ascending colon

Organs in RUQ?

• Liver

• Part of transverse colon

Organs in LUQ?

• Stomach

• Spleen

• Abdominal aorta

Organs in LLQ?

Descending colon

What is the purpose of percussion?

To identify presence of faecal loading or distended bladder