U3- Section C Nursing Assessment

Quadrants and Organs

  • RUQ (Right Upper Quadrant):

    • Liver

    • Gallbladder

    • Head of the Pancreas

    • Small Intestine

    • Ascending & Transverse Colon

    • Right Kidney

  • LUQ (Left Upper Quadrant):

    • Body & Tail of the Pancreas

    • Spleen

    • Small Intestine

    • Transverse & Descending Colon

    • Left Kidney

  • RLQ (Right Lower Quadrant):

    • Appendix

    • Small Intestine

    • Ascending Colon

    • Right Kidney

  • LLQ (Left Lower Quadrant):

    • Small Intestine

    • Descending & Sigmoid Colon

    • Left Kidney

Health History for GI System

Biographical Data

  • Name, DOB, religion, occupation, living address, etc.

Chief Complaint & History

  • Abdominal Pain

  • Changes in Weight

  • Changes in Bowel Habits

  • Indigestion (Pyrosis)

  • Nausea/Vomiting

  • Hematemesis (vomiting blood)

    • Note color: Green/Yellow

Past Health History

  • Gastrointestinal, Urinary, Liver Diseases

Medications

Family History

Psychosocial Profile (Social History)

  • Diet (types of foods consumed)

  • Alcohol Utilization

  • Exercise

Assessment of Symptoms

  • Common Symptoms:

    • Heartburn

    • Vomiting Blood

    • Constipation issues

Gastroesophageal Reflux Disease (GERD)

Definition

  • Condition where stomach contents flow back into the esophagus

Risk Factors

  • Obesity

  • Pregnancy

  • Smoking

  • Alcohol Consumption

Prevention Education

  • Avoid Tobacco Products

  • Limit Alcohol Intake

  • Eat Small Frequent Meals

  • Remain Upright 2 Hours Post Meals

  • Avoid Late Evening Snacks

  • Avoid Certain Foods (spicy, acidic, fatty)

  • Lose Weight if Overweight

Abdominal Assessment Considerations

General Guidelines

  • Save painful areas for last during examination.

  • Sequence of Assessment: Inspect, Auscultate, Percuss, Palpate.

Supplies Needed

  • Stethoscope, tape measure, light.

Patient Positioning

  • Position the patient supine with knees slightly flexed.

  • Ensure privacy and a comfortable environment.

Inspection

  • Observe general appearance, symmetry, and contour of abdomen.

  • Check for distention: Fat, fetus, feces, fibroids, flatulence, fluid (6 Fs).

Auscultation

  • Listen for bowel sounds and vascular sounds with specific parts of the stethoscope.

  • Assess bowel sounds for regularity and presence of bruits.

Percussion & Palpation

  • Percussion to assess size of organs and presence of fluid or gas.

  • Light palpation for surface characteristics, tenderness, or masses.

Elderly Considerations for GI System

  • Decreased appetite - risk for nutritional imbalances.

  • Rounded abdomen due to decreased muscle tone.

  • Increased risk of constipation due to reduced peristalsis and muscle tone.

Quadrants and Organs

  • RUQ (Right Upper Quadrant): Liver, Gallbladder, Head of the Pancreas, Small Intestine, Ascending & Transverse Colon, Right Kidney

  • LUQ (Left Upper Quadrant): Body & Tail of the Pancreas, Spleen, Small Intestine, Transverse & Descending Colon, Left Kidney

  • RLQ (Right Lower Quadrant): Appendix, Small Intestine, Ascending Colon, Right Kidney

  • LLQ (Left Lower Quadrant): Small Intestine, Descending & Sigmoid Colon, Left Kidney

Health History for GI System

  • Biographical Data: Name, DOB, religion, occupation, living address, etc.

  • Chief Complaint & History: Abdominal pain, changes in weight, changes in bowel habits, indigestion (pyrosis), nausea/vomiting, hematemesis (vomiting blood). Note color: Green/Yellow

  • Past Health History: Gastrointestinal, Urinary, Liver Diseases

  • Medications

  • Family History

  • Psychosocial Profile (Social History): Diet (types of foods consumed), alcohol utilization, exercise

Assessment of Symptoms

  • Common Symptoms: Heartburn, vomiting blood, constipation issues

Gastroesophageal Reflux Disease (GERD)

  • Definition: Condition where stomach contents flow back into the esophagus

  • Risk Factors: Obesity, pregnancy, smoking, alcohol consumption

  • Prevention Education:

    • Avoid tobacco products

    • Limit alcohol intake

    • Eat small frequent meals

    • Remain upright for 2 hours post meals

    • Avoid late evening snacks

    • Avoid certain foods (spicy, acidic, fatty)

    • Lose weight if overweight

Abdominal Assessment Considerations

  • General Guidelines: Save painful areas for last during examination.

  • Sequence of Assessment: Inspect, Auscultate, Percuss, Palpate.

  • Supplies Needed: Stethoscope, tape measure, light.

  • Patient Positioning: Position the patient supine with knees slightly flexed for comfort and privacy.

  • Inspection: Observe general appearance, symmetry, and contour of abdomen. Check for distention: Fat, fetus, feces, fibroids, flatulence, fluid (6 Fs).

  • Auscultation: Listen for bowel sounds and vascular sounds. Assess bowel sounds for regularity and presence of bruits.

  • Percussion & Palpation: Percussion to assess organ size and presence of fluid or gas; light palpation for surface characteristics, tenderness, or masses.

Elderly Considerations for GI System

  • Decreased appetite increases risk for nutritional imbalances.

  • Rounded abdomen due to decreased muscle tone.

  • Increased risk of constipation due to reduced peristalsis and muscle tone.