GI assessment: abdomen and nutrition

what is the purpose of the GI tract?

absorb nutrients

secretions

motility

metabolism

what health history questions should a nurse ask about doing a nutrition assessment?

- eating pattern

- usual weight

- changes in appetite, taste, smell, chewing, swallowing

- recent surgery, trauma, burns, infection

- chronic illness

- nausea, vomiting, diarrhea, constipation

- food allergies or intolerances

- medications and/or nutritional supplements

- self-care behaviors

- alcohol or illegal drug use

- exercise and activity patterns

- family history

what is included in a general routine screening during a nutritional assessment?

- client's general status and appearance

- client's body build, muscle mass, and fat distribution

- measure height and weight

- measure GMI

- changes in hydration

what are general signs of malnutrition?

weakness and fatigue, weight loss

what are signs of malnutrition with the eyes?

- dull, dry, color changes

- night blindness, corneal swelling

- red conjunctiva

what are signs of malnutrition with throat & mouth?

- cracks at foreigner or mouth

- beefy red tongue

- soft spongy, bleeding gums, swollen neck

- stomatitis (lips)

what are signs of malnutrition with musculoskeletal?

- calf pain, rickets, muscle loss

- bone pain and bow leg

what are signs of malnutrition with neurological?

- peripheral neuropathy, hyporeflexia, disoriented

- altered mental state

what are signs of malnutrition with skin, hair, and nails?

- dry, flaky skin

- dry skin with poor turgor

- rough, clay skin with bumps

- petechiae or ecchymoses

- sore that will not heal

- thinning dry hair

- spoon-shaped, brittle, or ridged nails

a body mass index of 18.5-24.9 would be considered

normal weight

a body mass index of 25-29.9 would be considered

overweight

a body mass index of 30-39.9 would be considered

obesity

a body mass index of 40 and above would be considered

extreme obestiy

a body mass index of less than 18.5 would be considered

underweight

how do you determine body mass index?

BMI = weight (kilograms)/ height (meters)^2

anthropometric measures

used to evaluate client's physicals growth, development, and nutritional status

what does anthropometric measure?

- height

- weight

- ideal body weight

- body mass index

- waist circumference

- hip to hip ratio

- triceps skinfold thickness

android obesity

large visceral fat stored mainly around the waist

gynoid obesity

fat located in hip/thighs

women with a >35" waist circumference and men with a >40" waist circumference are at an increased for what?

- heart disease

- type 2 diabetes

- metabolic syndrome

what are expected findings of an abdominal assessment?

- skin should be even, abdomen should be symmetric

- contour should be flat, scaphoid, rounded

- abdominal respiratory movement may be seen, slight peristaltic waves may be seen

what are abnormal findings of an abdominal assessment?

- distention

- severe scaphoid

protuberant

- redness or drainage from umbilicus

- diastasis recti: split the rectus muscles

- umbilical hernia

what is a nurse inspecting for when doing an abdominal assessment?

- contour

- symmetry

- skin

- umbilicus

- movements

- demeanor

normal skin findings of the abdomen:

- abdominal skin may be paler than general skin tone

abnormal skin findings of the abdomen:

purple discoloration at flake, jaundice, pale, redness, bruises

normal umbilicus findings of the abdomen:

color is similar to surrounding skin

abnormal umbilicus findings of the abdomen:

- cullen sign: bluish/purple discoloration around umbilicus

- grey-turner sign: bluish/purplish discoloration on abdominal flanks

normal contour findings of the abdomen:

- flat, rounded, scaphoid, evenly rounded

abnormal contour findings of the abdomen:

protuberant, distended abdomen

what 3 movements would the nurse be inspecting for when doing an abdomen assessment?

resp, aortic pulsations, peristaltic

normal abdominal resp. movement findings of the abdomen:

may be seen

abnormal abdominal resp. movement findings of the abdomen

diminished abdominal resp. or change in thoracic breathing

normal aortic pulsation findings of the abdomen:

- slight pulsation of abdominal aorta (visible in epigastrium)

- extends full length in thin people

abnormal aortic pulsation findings of the abdomen:

vigorous, wide, exaggerated pulsations could be seen with an abdominal aortic aneurysm

normal peristaltic wave findings of the abdomen:

normally not seen but can be seen in very thing people

abnormal peristaltic wave findings of the abdomen:

peristaltic waves increased and progress in a ripple like fashion from LUQ to RLQ

new striae

appear pink or bluish

old striae

slivery white, linear

abnormal striae

dark bluish-pink can be associated with cushing syndrome

how to auscultate for bowel sounds:

- use diaphragm of stethoscope

- best to start in RLQ and work counter clock wise

what would you hear when listening to bowel sounds?

high pitched, gurgles, slciks

normal bowel sounds

soft clicks and gurgles are heard at a rate of 5-30 per/min

hyperactive bowel sounds =

borborygmus

borborygmus

loud, prolonged gurgles "stomach growling"

abnormal bowel sounds

- hypoactive: indicate diminished bowel motility

hyperactive: sounds that are rushing, tinking, and high pitched

what causes hyperactive bowel sounds?

laxatives

dumping syndrome

what cause hypoactive bowel sounds?

- gastroparesis

- not unusual for patient to have hypoactive after surgery

- narcotics

what side of stethoscope is used to listen to vascular sounds?

bell

what is a nurse listening for when auscultating vascular sounds?

bruits

in what locations are vascular sounds listened for?

- over aorta arteries, renal artery, iliac artery

what is a normal finding with vascular sounds?

bruits aren't normally heard

percussion:

- dull over liver and spleen

- tympani over air

when is abnormal dullness heard with percussion?

over a distended bladder, large masses, or ascites

what does CVA tenderness test for?

kidney

light palpation:

- used to identify areas of tenderness and muscular resistance

- compress with a depth of 1 cm

normal light palpation finding:

abdomen is not tender and soft with no fuarding

abnormal light palpation finding:

involuntary, reflex guarding

deep palpation:

- to delineate abdominal organs and detect subtle masses

- compress 5-6 cm

normal deep palpation finding:

tenderness possible over xiphoid, aorta, cecum, sigmoid colon, and ovaries

abnormal deep palpation findings:

severe tenderness or pain

appendicitis

- rebound tenderness (Blumberg sign)

- iliopsoas muscle test: hold up right leg - push against thigh

blumberg sign

- rebound tenderness

- client will have rebound tenderness when examiner releases pressure

murphy sign

- push in the RUQ and have client take a deep breath

- if there is pain could mean gallbladder inflammation

psoas sign

pain in RLQ when leg is hyperextended, appendicitis

obtruder sign

pain in RLQ when hip & knee are flexed and leg is rotated internally & externally

- appendicitis or perforated appendix

rovising sign

- pain in RLQ during pressure in LLQ, appendicitis

developmental considerations: infants and toddlers

- height and weight should be measured at regular intervals

when is the most rapid period of growth in life cycle?

birth to 4 months

nutritional recommendations for infants/toddlers:

- optimal source of nutrition for infants: breast milk or formula

- fats needed for brain and CNS development through 2 years of age

what is measured in an infant/toddler routinely?

length

weight

head circumference

chest circumference

abdominal shape/contour of an infant/toddler:

rounded abdomen

history for infants and children:

- dietary histories

- infant breastfeed or bottle fed

- child's willingness to eat what is prepared

- overweight and obesity risk factors

- do you prop bottle up for infant

developmental considerations: adolescence

- rapid growth (middle school years +)

- need increased calories, protein, calcium, & iron for growth and hormone development

history for adolescents:

- present weight and their feelings/perceptions

- use of performance - enhancing agents? energy drinks?

what are overweight and obesity risk factors for adolescents?

- skipping meals

- consuming fast foods

- sweetened beverages

developmental considerations: adulthood

- nutrients needs stabilize

- may see poor habits with increased stress

- importance time for education to preserve health and prevent onset of chronic disease

developmental considerations: aging adult

- major risk factors for malnutrition

- normal physiologic changes that affect nutritional status

major risk factors for malnutrition in aging adults:

poor physical or mental health, social isolation, alcoholism, limited functional ability, poverty/fixed income, and polypharmacy

normal physiologic changes that affect nutritional status in aging adults

poor dentitions, decreased visual acuity, decreased saliva production, slowed GI motility, decreased GI absorption, diminished olfactory and taste sensitivity

developmental considerations: aging adults height

- declines very slowly from early 30s

- height measures may not be accurate because of osteoporotic changes

developmental considerations: aging adults BML and waist to hip ratio

are better indicators of obesity in this age group

what vitamins are adequate for an aging adult?

calcium and vitamin

cultural competence

- foods and eating customs are culturally diverse

- each person has unique cultural heritage that may affect nutritional status

- newly arriving immigrants may be at nutritional risk

when palpating the abdomen of a patient, the nurse notes tenderness in the left upper quadrant with deep palpation. What structure is most likely involved?

A. appendix

B. liver

C. spleen

D. gallbladder

C

when the nurse percusses at the right costovertebral angle, the patient complains of a sharp pain. What may this indicate?

A. appendicitis

B. kidney infection

C. normal response

D. enlarged liver

B

a pregnant patient is concerned about silvery white, linear, jagged marks on her abdomen. what is the best response by the nurse?

A. "these are due to stretching of the skin and are normal during pregnancy"

B. " I will inform the doctor to see if he wants to examine you"

C. " I had those same kinds of marks when I was pregnant. They go away"

D. "it must really be embarrassing to have those marks"

A

which of the following are appropriate when auscultating for bowel sounds. select all that apply

a. auscultate after percussion

b. use the bell of stethoscope

c. hold the stethoscope lightly against the skin

d. count for one full minutes

e. begin in the RLQ

c,e

the nurse is not hearing any bowel sounds when assessing a patient. what should the nurse do next?

a. document bowel sounds as hypoactive

b. percuss the abdomen to stimulate bowel sounds

c. wait 10 minutes then assess again

d. listen for 5 minutes to determine if absent

d

the patient complains of having "a lot of gas." what should the nurse expect to hear on percussion of the abdomen?

a. tympany

b. hyperresonance

c. dullness

d. flat

b

which of the following are measures to enhance relaxation of a patient during an abdominal assessment? select all that apply

a. have arms above head

b. examine painful areas last

c. use distraction

d. have patient void first

e. hand palpating should be high and pointing down

b,c,d

during an assessment of an 80 year old patient, the nurse notes that the liver and right kidney are easily palpable. what is the best response by the nurse?

a. call the physician immediately

b. reassess again in 4 hours

c. teach the patient relaxation methods

d. document these as normal findings

d

a positive fluid wave test occurs with what?

a. splenomegaly

b. distended bladder

c. bowel obstruction

d. ascites

d

the mother of an 8 month old African American infant is concerned about a visible bulge along the midline of the infants abdomen. what is the best response by the nurse?

a. "this is known as an umbilical hernia. it usually disappears by age one"

b. "this is something you should have your doctor examine"

c. "this is the result of the separation of muscles. it usually disappears by early childhood"

d. "this may indicated your child is eating too much. tell me about his feeding schedule"

c

how should the nurse assess for a distended bladder?

a. percuss and palpate in the lumbar region

b. inspect and palpate in the epigastric region

c. auscultate and percuss in the inguinal region

d. percuss and palpate in the suprapubic region

d

while examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. what would the nurse suspect?

a. pulsations of the renal arteries

b. labored respiratory movements

c. pulsations of the abdominal aorta

d. peristaltic movements

c

the physician comments that the patient has borborygmi. what does this term refer to?

a. a loud continuous hum

b. a peritoneal friction rub

c. hypoactive bowel sounds

d. hyperactive bowel sounds

d

what percussion finding would the nurse expect to find in a patient with a large amount of ascites?

a. dullness across the abdomen

b. flatness in the right upper quadrant

c. hyperresonance in the left upper quadrant

d. tympany in the right lower quadrant

a

the nurse hears a blowing sound when auscultating for vascular sounds. the nurse response is based on what?

a. this is a bruit

b. this is a normal finding

c. this is borborygmus

d. this is a positive blumberg sign

a

ascites

abnormal accumulation of fluid in the abdomen

tests for ascites:

fluid wave and shifting dullness