NURS 1145 GI Assessment, Rectum/Anus/Prostate, Urinary Assessment

In every other system the order is

Inspect → Percuss → Palpate

In GI

you MUST auscultate BEFORE percussion and palpation, because touching first changes bowel sounds

GI ORDER

Inspect → Auscultate → Percuss → Palpate (IAPP)

INSPECT

Look at the belly: contour, symmetry, skin, umbilicus, pulsations, scars. Ask patient to cough or sit up → reveals hernias.

AUSCULTATE

Listen FIRST (before any touching). Listen for bowel sounds in all 4 quadrants AND vascular sounds (bruits). Use the DIAPHRAGM for BS, BELL for bruits.

PERCUSS

Tap for tympany (air = normal) vs. dullness (solid/fluid). Check liver span, splenic dullness, CVA tenderness (kidneys), ascites.

PALPATE

Light first (1–2 cm), then deep (4–6 cm) only if pain with light. Palpate painful areas LAST.

What to do when the patient says it hurts?

Palpate that painful spot LAST. Why? Touching it first makes the whole abdomen tense up and ruins the rest of your exam.

RUQ (Right Upper) = Abdominal Quadrants

Liver, gallbladder, right kidney

LUQ (Left Upper) = Abdominal Quadrants

Spleen, stomach, left kidney

RLQ (Right Lower) = Abdominal Quadrants

Appendix → pain here = think appendicitis

LLQ (Left Lower) = Abdominal Quadrants

Sigmoid colon, left ovary = diverticulitis

Suprapubic / Hypogastric (Abdominal Quadrants)

Bladder → dull percussion = full bladder, UTI, retention

Epigastric (top middle) = Abdominal Quadrants

Stomach = common tenderness from coffee, food, acid

Solid Organs (no gas)

1.Liver 2.Pancreas 3.Spleen 4.Kidneys 5.Ovaries

Hollow Organs (carry gas/fluid)

1.Stomach 2.Gallbladder 3.Small intestine / Colon 4.Bladder

Solid organs percuss

DULL.

Hollow organs percuss

TYMPANY (drum sound).

Most of the belly

Tympany because of gas = that is normal

Tympany (drum sound) = Percussion Sounds

AIR / gas = normal finding across most of the belly

Dullness (thud sound) = Percussion Sounds

Solid organ OR fluid (liver, full bladder, ascites, tumor)

Liver span (normal) = Percussion Sounds

6–12 cm (about 2.5–5 inches) along right midclavicular line

Splenic dullness (Percussion Sounds)

Should NOT be percussed; if dull = enlarged spleen. DO NOT percuss if injury suspected = risk of rupture.

CVA tenderness (Percussion Sounds)

Tap lower back in the costovertebral angle. Pain = kidney infection OR kidney stones (NOT a bladder infection alone)

Normal (gurgling) = Bowel Sounds

Present, active digestion = good sign

Hypoactive (quiet/absent) = Bowel Sounds

Slow or stopped movement: post-surgery, constipation, bowel obstruction, ileus = BAD sign

Hyperactive (very loud, rushing) = Bowel Sounds

Fast movement: diarrhea, GI irritation, early obstruction

Bruits (whoosh sound) = Bowel Sounds

ABNORMAL = narrowed artery (stenosis). Use the bell. Check aorta, renal, iliac, femoral arteries.

McBurney's Sign (Appendicitis Tests)

Press 1/2 to 2/3 of the way between the belly button and the right hip bone (RLQ). Pain = appendicitis. Memory: 'McBurney = Appendix is burning'

Rebound Tenderness (Blumberg's Sign) = Appendicitis Tests

Press slowly and deeply, then RELEASE FAST. Pain is WORSE on release = positive = inflammation (appendicitis). Give patient clear instructions first.

Rovsing's Sign (Appendicitis Tests)

Press the LEFT lower quadrant (LLQ) = patient feels pain in the RIGHT lower quadrant (RLQ). Why? You're pushing intestinal contents toward the appendix.

Iliopsoas Test (Appendicitis Tests)

Lift the patient's right leg back (hip extension). Pain = appendix irritation. Also used for appendicitis suspicion.

Obturator Test (Appendicitis Tests)

Bend and internally rotate the leg. Pain = ruptured appendix OR pelvic abscess.

McBurney + Rebound + Rovsing + Iliopsoas + Obturator

All appendix problems.

Murphy's Sign is for the

GALLBLADDER (different organ!).

Murphy's Sign (Other Special Tests)

GALLBLADDER → Press under right ribs and ask patient to inhale deeply. Patient suddenly STOPS breathing (inspiratory arrest) = positive = gallbladder problem (cholecystitis). Memory: 'Murphy = Can't MURmur (breathe)'

Guarding (Other Special Tests)

Abdomen stiffens when you touch it = body protecting itself. Could mean PERITONITIS (infection in peritoneal cavity) from ruptured appendix, ruptured cyst, etc. Very serious.

Fluid Wave Test (Other Special Tests)

Two examiners: tap one side, feel wave on the other side with a hand in the middle. Positive = fluid (ASCITES).

Shifting Dullness (Other Special Tests)

Percuss: tympany → dull. Have patient roll to one side; dullness SHIFTS with gravity. Positive = ascites (fluid in abdomen).

Ballottement (Other Special Tests)

Feel a floating mass with two hands. Example: feeling a fetal head = but used for any floating mass.

A student felt a large mass in the RLQ of a patient on a ventilator. Nobody else had palpated the patient. It turned out to be a hematoma = the patient had been internally bleeding and the hemoglobin had dropped 3 grams in one day.

The ASSESSMENT found it. This is why you always palpate fully = Palpation Saves Lives

Light palpation

1–2 cm depth = check for tenderness, muscle tone, surface characteristics

Deep palpation

4–6 cm depth = do this ONLY if patient has pain on light palpation, or you're looking for masses/organs

Palpation Technique

Use the flat of 3 fingers, slide across (don't jab from spot to spot)

Strategies to reduce guarding during palpation

Bend knees, hand behind head, use patient's own hand, warm your hands, good lighting

Palpate painful areas

LAST

What You Always Assess (Bowel Movements)

1.Color 2.Odor 3.Consistency (Bristol Stool Chart) 4.Last bowel movement 5.Normal pattern for that patient

Black / Tarry (Melena) = Stool Colors

Digested blood = bleeding HIGH in GI tract (stomach or upper intestines). SERIOUS.

Bright Red blood (Stool Colors)

Bleeding NEAR rectum or anus. Could be hemorrhoids, fissure, or something more serious.

Dark but NOT tarry (Stool Colors)

Iron supplements = not necessarily bleeding

Green (Stool Colors)

Fast digestion, ate lots of vegetables, bile

Yellow/greenish (Stool Colors)

Bile = helps digest fat

Black (Rectal Bleeding)

Back (upper GI = digested blood)

Bright Red (Rectal Bleeding)

Right there (rectum/anus)

If it's dark but not tarry (Rectal Bleeding)

Think iron meds

Type 1–2 (hard, lumpy, like pellets) = Bristol Stool Chart

CONSTIPATION

Type 3–4 (smooth, sausage-shaped) = Bristol Stool Chart

NORMAL = this is what you want

Type 5–7 (mushy to watery) = Bristol Stool Chart

DIARRHEA

Abdominal Distention Causes

1.Obesity 2.Ascites (fluid) = important! Check with fluid wave or shifting dullness 3.Gas / Flatus 4.Pregnancy 5.Feces (constipation) 6.Tumor 7.Ovarian cyst

Abdominal Distention Memory trick

Fat, Fluid, Fetus, Feces, Flatus (gas), Tumor, Ovarian Cyst

Hypoactive / Absent (Abnormal Bowel Sounds)

Post-surgery (ileus), constipation, bowel obstruction = BAD

Hyperactive (Abnormal Bowel Sounds)

Diarrhea, GI irritation, early obstruction

Bruits (vascular) = Abnormal Bowel Sounds

Arterial stenosis = ABNORMAL

Enlarged liver (hepatomegaly) = Palpation Abnormalities (Enlarged Organs)

Hepatitis, alcohol abuse, liver cancer

Nodular (bumpy) liver = Palpation Abnormalities (Enlarged Organs)

Cirrhosis = serious

Enlarged spleen = Palpation Abnormalities (Enlarged Organs)

Infection, blood disorders = do NOT percuss if injury suspected

Enlarged gallbladder = Palpation Abnormalities (Enlarged Organs)

Blockage or inflammation

Aortic aneurysm = Palpation Abnormalities (Enlarged Organs)

EMERGENCY = large, pulsating mass in the belly. Could rupture and is life-threatening.

Aortic Aneurysm = EMERGENCY

A large pulsating mass felt during palpation. It can rupture and is immediately life-threatening.

Umbilical hernia (Inspection Abnormalities)

Belly button bulges out = visible when patient coughs

Incisional hernia (Inspection Abnormalities)

Bulge along a surgical scar = visible when patient coughs

Scaphoid contour (Inspection Abnormalities)

Sunken belly = think malnutrition or very thin patient

Protuberant contour (Inspection Abnormalities)

Big, bulging belly = gas, fat, fluid, pregnancy, tumor

Normal pulsation (Inspection Abnormalities)

Small movement is okay; LARGE pulsation = possible aneurysm

Ostomy (stoma) = Inspection Abnormalities

Normal = bright red, moist, round. Abnormal = pale (anemia) or skin breakdown (irritation)

The GI system itself does NOT completely break down with age.

BUT other systems (heart, nerves) slow down, which affects digestion. Also, changes in the liver = drugs stay in the body longer.

Esophagus (Age-Related GI Changes)

Decreased motility and pressure → more regurgitation (food comes back up)

Stomach (Age-Related GI Changes)

Lining degenerates, less acid + enzymes → slower digestion, harder to break down food

Vitamin B12 Absorption (Age-Related GI Changes)

Fewer parietal cells → less intrinsic factor produced → poor B12 absorption. Memory: 'Old stomach = can't absorb B12'

Small intestine (Age-Related GI Changes)

Thinner, less surface area → decreased fat absorption and B12 absorption; intolerance of fatty foods (less lipase)

Large intestine (Age-Related GI Changes)

Weaker muscles, slower peristalsis → CONSTIPATION; less active gut bacteria → food intolerance

Liver (Age-Related GI Changes)

Smaller, less blood flow → slower metabolism of medications, alcohol, hormones. Memory: 'Old liver = drugs stay longer'

Because the older adult liver is smaller and receives less blood flow

Medications are metabolized more slowly.

Morphine dose for a 30-year-old adult might be quartered for an older adult

Because they can't process it at the same rate. This applies to cardiac meds too.

Physical Exam of Older Adults

1.Same steps = inspect, auscultate, percuss, palpate 2.More abdominal fat; less subcutaneous fat on arms/legs 3.Belly is softer → organs easier to palpate 4.Liver is SMALLER (not bigger) in older adults = may not feel it under the ribs unless there's disease 5.Ask about: new abdominal pain, constipation, water intake, fiber, laxative use, urinary leaking

Rectum, Anus, & Prostate Assessment Subjective Data Questions to Ask

1.Bowel habits: 'How often do you go? Any changes?' 2.Rectal bleeding: 'Blood in your stool? What color?' 3.Symptoms: pruritus (itching), hemorrhoids, fissures, fistulas 4.Medications: laxatives, stool softeners, IRON (turns stool dark = not bleeding) 5.Lifestyle: fiber intake, last rectal exam

Rectal Bleeding Follow-up Questions

1.When did it start? Constant or intermittent? 2.Color and amount? 3.Any cramping? = think ulcerative colitis 4.Constipation? = hard stool can tear the anus (fissure) 5.Fatigue? = could mean anemia from blood loss

Objective Exam Equipment

1.Penlight 2.Lubricating jelly 3.Gloves 4.Guaiac test container (checks for hidden/occult blood)

Pilonidal cyst (Anorectal Abnormal Findings)

Painful lump near tailbone = may have pus. Memory: 'Pilo = Pillow, sits near tailbone'

Anorectal fistula (Anorectal Abnormal Findings)

Tunnel from INSIDE rectum to OUTSIDE skin = always a connection from one area to another. May leak fluid.

Fissure (Anorectal Abnormal Findings)

Small TEAR in the anus = very painful, from hard stool. 'Like a paper cut but worse'

Hemorrhoids (Anorectal Abnormal Findings)

Swollen veins = inside or outside the anus. Can bleed bright red blood. Itchy or painful. Very common.

Pruritus ani (Anorectal Abnormal Findings)

Itchy anus = causes: poor hygiene, irritation, infection

Rectal prolapse (Anorectal Abnormal Findings)

Rectum comes OUT of the anus (looks like a red donut). Happens with straining. Abnormal.

Abscess (Internal Rectal Abnormalities)

Pocket of pus = pain, swelling, fever. Needs to be drained (incision).

Polyp (Internal Rectal Abnormalities)

Small growth = usually NOT painful, but CAN become cancer. Found on colonoscopy.

Fecal impaction (Internal Rectal Abnormalities)

Hard stool stuck inside = patient can't go. Liquid stool may leak AROUND it. Common in elderly.

Carcinoma (cancer) = Internal Rectal Abnormalities

Signs: rectal bleeding, weight loss, change in bowel habits

Diagnostic Test = Colonoscopy

Camera goes inside the colon to look for cancer, polyps, and bleeding. BONUS: polyps can be REMOVED during the procedure.

Normal Baseline = Urinary Assessment

1.Urine color: yellow and clear ('like light apple juice') 2.Frequency: 4–5 times per day 3.Always ask: 'When was your last void?' and 'Any pain with urination (dysuria)?' 4.This is part of EVERY shift assessment