NSB103 Health Assessment - Gastrointestinal Assessment Notes

Gastrointestinal Assessment

Overview of the Gastrointestinal (GI) and Digestive System

  • Purpose:
    • Digestion of food to meet the body’s nutritional needs.
    • Elimination of waste resulting from digestion.

Organs and Functions of the Digestive System

  • Mouth: Salivary enzymes begin carbohydrate digestion and break up food particles; moistens and lubricates food. The enzyme amylase digests carbohydrates.

  • Pharynx: Directs food into the esophagus to prevent choking.

  • Esophagus: Carries food down from the mouth to the stomach.

  • Stomach: Secretes gastric juice and hydrochloric acid, activates enzymes, continues to break down food and kill off any pathogens; stores and churns food. The enzyme pepsin digests protein.

  • Small Intestine: Digests protein, fats, and carbohydrates; bacterial metabolism plus nutrient and excess water absorption. The surface is covered in villi for greater absorption. Site of fructose malabsorption and celiac disease.

  • Large Intestine: Also called the colon; absorbs water and electrolytes from stool; contains beneficial bacteria which help produce certain vitamins; forms and stores feces.

  • Rectum: The lower end of the large intestine, leading to the anus; stores and expels feces.

  • Anus: The opening at the end of the digestive tract where bowel movements leave the body.

  • Liver: The largest organ inside the body; makes bile (fluid that helps break down fats and gets rid of wastes in the body); changes food into energy; clears alcohol, some medicines, and poisons from the blood; stores vitamins and iron; destroys old blood cells.

  • Gallbladder: Stores the bile made in the liver, then empties it into the small intestine to help digest fats; stones can form within.

  • Pancreas: A gland that makes enzymes for digestion and bicarbonate to neutralize stomach acid; also makes the hormone Insulin, which helps the body turn food into energy, and regulates blood sugar levels.

  • Appendix: A pouch attached to the first part of the large intestine; no one knows its function.

Upper GI System

  • Includes the mouth, esophagus, and stomach.

Lower GI System

  • Includes the small intestine, large intestine, rectum, and anus.
  • Solid viscera: spleen, pancreas, liver (accessory organs)

Intestinal Lining

  • Small Intestine
    • Covered in villi for greater absorption
  • Large Intestine
    • No Villi

Abdominal Muscles

  • External abdominal oblique

  • Internal abdominal oblique

  • Transverse abdominis

  • Function: To protect the internal organs and allow normal functional compression activities (e.g., coughing, sneezing, urination, defecation, and childbirth).

  • During pregnancy, the rectus abdominis separates, impacting the pregnant woman’s ability to set her core muscles.

Focused Gastrointestinal System Assessment

  • Review baseline assessment data.
  • Perform hand hygiene.
  • Ensure comfort/privacy; explain procedure.
  • Approach from the right-hand side of the patient; position supine if possible.
  • Inspect abdomen.
  • Auscultate for the presence of bowel sounds.
  • Gently percuss over the abdomen.
  • Lightly palpate each quadrant.
  • Assess recent and frequency of bowel movements.
  • Determine frequency of gastrointestinal assessment based on the patient’s condition.

Objective Assessment of the Abdomen

  • Four main techniques:
    • Inspection
    • Auscultation
    • Percussion
    • Palpation

Abdominal Regions and Quadrants

  • Regions: Right hypochondriac, epigastric, left hypochondriac, right lumbar, umbilical, left lumbar, right iliac, hypogastric, left iliac
  • Quadrants: Right Upper (RUQ), Right Lower (RLQ), Left Upper (LUQ), Left Lower (LLQ)

Abdominal Regions and Pain Indications

  • Right: Cholelithiasis, biliary colic, acute cholecystitis, acute cholangitis, acute hepatitis, liver abscess, Budd-Chiari syndrome, portal vein thrombosis, acute myocardial infarction, acute pancreatitis, chronic pancreatitis, peptic ulcer disease, GERD, gastritis, functional dyspepsia, gastroparesis, nephrolithiasis, pyelonephritis, constipation, infectious colitis, ischemic colitis, appendicitis, nephrolithiasis, pyelonephritis, infectious colitis, inflammatory bowel disease, inguinal hernia, ovarian cyst/torsion, ectopic pregnancy (unilateral), PID (bilateral).
  • Left: Splenomegaly, splenic infarct, peptic ulcer, gastritis, nephrolithiasis, pancreatitis, duodenal ulcer, nephrolithiasis, cystitis (UTI), acute urinary retention, appendicitis, inflammatory bowel disease, ovarian cyst, nephrolithiasis, pyelonephritis, constipation, infectious colitis, ischemic colitis, diverticulosis/diverticulitis, nephrolithiasis, pyelonephritis, irritable bowel syndrome, infectious colitis, inguinal hernia, ovarian cyst/torsion, ectopic pregnancy (unilateral), PID (bilateral).

Assessment: Inspection

  • Contour
  • Symmetry
  • Skin: color, moisture, scarring
  • Pulsation or movement
  • Umbilicus: midline, inverted, everted, swelling
  • Striae – stretch marks

Assessment: Auscultation

  • All quadrants systematically, comparing quadrants
  • Before percussion and palpation
  • Listen for bowel sounds for 1-3 minutes (present/absent; diminished/hyperactive)
  • Normal: low-pitched continuous gurgles

Different Bowel Sounds

  • Normal Bowel Sounds: Intestines transporting fluid and digested food through the intestinal lumen at a normal rate. Sounds are approximately every 5 to 15 seconds.
    • Possible Cause: Normally functioning intestine.
  • Hypoactive Bowel Sounds: Intestines transporting fluid and digested food through the intestinal lumen at a decreased rate probably due to inactivity of smooth muscle in the bowel. Sounds are approximately every 20 to 30 seconds; can be longer.
    • Possible causes: Paralytic ileus, peritonitis, decreased bowel motility, late intestinal obstruction.
  • Hyperactive Bowel Sounds: Intestines transporting fluid and digested food through the intestinal lumen at an increased rate, probably due to rapid passage of air and fluid through the intestines. Sounds can be as frequent as every second.
    • Possible Causes: Diarrhea, early intestinal obstruction, gastroenteritis, anxiety
  • High-pitched Rushing or Tinkling Sounds (Borborygmi): Hyperperistalsis from intestinal straining to push fluid and/or air past an obstruction, or fluid and/or air under pressure. Very loud sounds; may be heard without a stethoscope.
    • Possible Causes: Intestinal obstruction, dilated bowel loops, fecal impaction, gastroenteritis.
  • Absent Bowel Sounds: Absence of intestinal motility; ominous finding
    • Possible Causes: Peritonitis, late obstruction (ileus), perforation, trauma.
  • Abdominal Bruits: Turbulent blood flow in an artery.
    • Possible Causes: Aneurysm, thin/emaciated patient, renal artery stenosis.

Assessment: Percussion

  • To determine the size of solid organs and the presence of masses, fluid, and gas.
  • All 4 quadrants
  • Typically undertaken by medical staff and expert nursing staff

Assessment: Palpation

  • Assessing the shape and size of organs.
  • Tenderness or pain (rebound tenderness)
  • Light or deep palpation
  • Liver and spleen palpation
  • Muscle rigidity
  • Palpate painful areas last
  • Guarding – involuntary reflex (local rigidity)
  • Stand to the right side of the patient.
  • Patient relaxed.
  • All regions systematically.
  • Watch the patient’s facial expression all of the time.
  • Non-tender areas first.

Focused Gastrointestinal History - Subjective Data

  • Change in appetite
  • Weight gain or weight loss
  • Presence of dysphagia
  • Intolerance to certain foods
  • Nausea and/or vomiting
  • Change in bowel habits
  • Abdominal pain

Other Subjective Data

  • Medications (laxatives, stool softeners, iron supplements, opioids)
  • Nutritional assessment
    • Difficulty chewing
    • Pain in relation to eating and digestion
    • Meal preferences
  • Social history and lifestyle risk factors
    • Meal preparation difficulties
    • Financial constraints
    • Ability to access shops
  • Sleep and rest
  • Activities

Nutritional Assessment

  • Height
  • Weight (changes)
  • Typical diet and recent changes to diet
  • Waist/girth measurement
  • BMI
  • Nutritional Risk: Overnutrition
    • The intake of nutrients is oversupplied and the amount of nutrients exceeds the amount required for normal growth, development, and metabolism.
  • Nutritional Risk: Undernutrition – Risk Factors
    • Hospitalization
    • Social isolation
    • Poverty
    • Disability (inability to purchase and/or prepare food)
    • Inability to feed self
    • Malabsorption
    • Poor appetite

Waist Measurement

  • Women:
    • Increased risk: more than 80 cm
    • Greatly increased risk: more than 88 cm
  • Men:
    • Increased risk: more than 94 cm
    • Greatly increased risk: more than 102 cm

Dietary Guidelines

  • The average adult needs about 8700kj per day.
    1. Eat enough food from each of the 5 food groups every day.
    2. Choose different varieties of food from each food group.
    3. Eat plenty of plant foods; moderate amounts of animal foods; small amounts of extra foods, margarines, and oils.
    4. Drink plenty of water.

Nutrition - Developmental Considerations

  • Newborn: Suck and swallow, breastfeeding/infant formula, frequency of feeds, volume of feeds.
  • Toddler: Teeth, move food around their mouth, chew, and swallow. Typical daily meal plan: Solid foods and fluids, snacks, sugary drinks, bottles in bed (dental caries), allergies, intolerances, medications.
  • Youth: Rapid growth = increased energy requirements. Typical daily eating: Perceptions of their weight, understanding of balanced diet, extreme use of diets.

Indicators of Good Nutritional Status

  • Alert, energetic
  • Good attention span
  • Weight within healthy range
  • Firm, well-developed muscles
  • Skin elastic, smooth
  • Eyes bright and clear
  • Hair shiny, minimal loss
  • Mucous membranes pink and moist
  • Abdomen flat and firm
  • No skeletal changes

Indicators of Poor Nutritional Status

  • Withdrawn, fatigued
  • Inattentive and irritable
  • Overweight or underweight
  • Wasted appearance, flaccid muscles
  • Skin dull, pasty
  • Eyes dull, pale conjunctiva
  • Mucous membranes: red, boggy, bleed easily
  • Abdomen flaccid or distended
  • Skeletal changes

Under Nutrition and the Older Adult

  • Loss of appetite
  • Reduced sensation of taste
  • Medication induced
  • Inability to chew food
  • Inability to swallow food
  • Inability to digest food
  • Reduced saliva (dry mouth)
  • Social implications (financial, situational, physical, psychological)
  • Risk factors: Oral health
  • Impacts on nutrition, socialization, and positive self-concept
  • Inability to chew due to:
    • Loss of teeth
    • Painful teeth and gums
    • Sensitive teeth
    • Receding, bleeding gums
    • Ill-fitting dentures

Hydration - Health Assessment

  • Moist skin and mucous membranes
  • Bright, clear eyes
  • Normotensive (normal BP)
  • Normal range heart rate
  • Normal range body temperature
  • Lucid and oriented
  • Feces soft and formed
  • Urine – straw colored
  • Fluid input ~ 1500 mLs per day
  • Urine output reflects the input
  • Stable weight

Dehydration in Adults

  • Hypotension
  • Thirst
  • Sunken eyes
  • Dry mouth
  • Cracked lips
  • Poor skin turgor
  • Fever
  • Tachycardia
  • Dry mucous membrane
  • Tears decreased
  • Mental disorientation/confusion
  • Weight loss
  • Oliguria (dark amber color)
  • Input less than 1500 mLs/day

Dehydration in Infants

  • Output > input
  • Oral intake
  • Fluid loss (vomiting and diarrhea)
  • Check nappy contents
  • Dehydration described as a percentage of body weight dehydrated
  • Tachycardia
  • Dry skin & mucous membranes
  • Sunken anterior fontanelle
  • Circulation changes (mottling, coolness)
  • Loss of elasticity
  • Prolonged capillary refill
  • Oliguria
  • Reduced tears
  • Irritable

Hydration - Overhydration

  • Drinking too much fluid
  • Diabetes insipidus
  • Retaining too much fluid (kidney, cardiovascular issues)
  • Bounding pulse
  • Hypertensive
  • Raised Jugular Venous Pressure
  • Edema (dependent and pitting)
  • Neurological changes (level of consciousness, confusion, headache, seizures)
  • Respiratory (pulmonary congestion)
  • Polyuria (pale urine)
  • Nausea and vomiting
  • Muscle spasm and weakness

Faecal Elimination

  • Normal feces: Soft, formed stools influenced by diet
    • Newborn: Meconium (black tarry)
    • Adult: Brown to green color
  • Constipation: Decrease in frequency, passing hard, dry, pebbly stool
  • Diarrhea: Frequent bowel movements, loose to fluid motions
  • Assessment: Changes from normal routine, size, consistency, and color should be noted.

The Bristol Stool Chart:

  • Type 1: Separate hard lumps, like nuts (hard to pass)
  • Type 2: Sausage-shaped but lumpy
  • Type 3: Like a sausage but with cracks on its surface
  • Type 4: Like a sausage or snake, smooth and soft
  • Type 5: Soft blobs with clear-cut edges (passed easily)
  • Type 6: Fluffy pieces with ragged edges, a mushy stool
  • Type 7: Watery, no solid pieces. Entirely liquid

Common Health Problems Related to the Upper GI System

  • Upper GI tract (mouth, esophagus, stomach, duodenum):
    • Mucositis (mouth ulcers)
    • Esophageal varices
    • Indigestion; gastroesophageal reflux disease (GORD)
    • Gastritis; gastroenteritis
    • Dysphagia
    • Peptic ulcers
    • Pyloric stenosis
    • Hiatus hernia
    • Nausea and vomiting (symptoms of other causes)

Common Health Problems Related to the Lower GI System

  • Lower GI tract:
    • Constipation
    • Diarrhea
    • Fecal incontinence
    • Prolapse of the bowel
    • Bowel cancer
    • Celiac disease
    • Crohn’s disease
    • Ulcerative colitis
    • Diverticular disease
    • Irritable bowel syndrome
    • Hemorrhoids
    • Other: Dehydration/Malnutrition

Clinical Reasoning Cycle

  • Consider the person and the context (Who is the person? Where are they living? Who supports them? What is their experience? Present, past, family history).
  • Collect cues and information (Subjective and objective Data).
  • Processing the information (Compare the data against normal parameters. Analyze, organize, categorize).
  • Identify potential health issues/problems (Relate back to the data for relevance and direction).
  • Set goals in collaboration with the person and their family (Each goal is aligned with each potential health issue or problem).

Potential Health Problems Related to the Gastrointestinal System

  • Inadequate nutrition relating to malabsorption
  • Inadequate nutrition relating to decreased appetite
  • Anxiety relating to fecal incontinence
  • Constipation relating to decreased physical activity
  • Impaired hydration relating to nausea and vomiting
  • Imbalanced nutrition related to an inability to purchase food due to financial constraints
  • Imbalanced nutrition relating to a reduction in mobility
  • Social isolation due to the inability to meet with friends for social morning tea gatherings
  • Goals: realistic, timely, achievable, collaborative. For example: Reduce symptoms of nausea and vomiting to improve hydration levels.