Nursing Assessment of the Gastrointestinal System

DR\ Nermen Abd Elftah

OBJECTIVES At the end of this class, the student will be

able to: Identify landmarks for the abdominal

assessment Correctly perform techniques of inspection,

auscultation, percussion and palpation Differentiate normal from abnormal findings Document findings

The digestive system

Concepts of Structures and FunctionsThe GI System consists of the GI tract and its associated organs and glands

A. GI tract

1. mouth

2. esophagus

3. stomach

4. small intestines

5. large intestines

6. rectum

7. anus

B. Associated organs

1. liver

2. gall bladder

3. pancreas

Structures and Function of the GastroIntestinal System

Main Function of the GI System?????

Supply Nutrients to body cells

Process of Digestion and Elimination

A. Ingestion ( Taking In Food)

B. Digestion ( Breakdown of Food)

C. Absorption ( transfer of food products into the circulation)

D. Elimination

Digestion and AbsorptionFood is broken down into small and simple

compounds enough to be absorbed into the bloodstream by diffusion or active

transport.

Effects of Aging on the Gastrointestinal TractA. Teeth may loosen up from the supporting gums and bones.B. Decreased output of the salivary glands leads to dryness of mucous

membranes and increased susceptibility to breakdown, difficulty swallowing and decrease stimulation of the taste buds.

C. Decreased secretion of digestive enzymes and bile – decrease ability to digest and absorb food.

>> impaired absorption of fat and fat soluble vitamins D. Atrophy of gastric mucosa leads to decrease HCl acid production.

>>decrease iron and B12 absorption – anemia>>proliferation of bacteria – diarrhea and infection

E. Decrease peristalsis in the large intestine, decrease muscular tone of the intestinal wall and decrease abdominal muscle strength – decrease sensation to defecate and increase incidence of constipation.

Regions of the Abdomen Epigastric: area between costal margins Umbilical: area around umbilicus Suprapubic or hypogastric: area above

pubic bone. or

RUQ LUQRLQ LLQ

Abdomen

Right Upper Quadrant (RUQ)

liver, gallbladder, duodenum, right kidney and hepatic flexure of colon

Abdominal Anatomy & Physiology Left Upper Quadrant (LUQ): Stomach Spleen Left lobe of liver Body of Pancreas Left kidney and adrenal Splenic flexure of colon Part of transverse and descending colon

Right Lower Quadrant (RLQ)

Cecum, appendix (in case of female, right ovary & Right ureter

Abdominal Anatomy & Physiology

Left Lower Quadrant (LLQ): Part of descending colon Sigmoid colon Left ovary and tube Left ureter Left spermatic cord

Abdominal Anatomy & Physiology

Midline: Aorta Uterus Bladder

Peripheral Exam Abdominal Exam

Hand Arms Face Neck: LN Chest

Inspection Palpation Percussion (Ascites) Auscultation

GIT Exam

Nail

Clubbing thickening of the fingertips that gives them an abnormal rounded appearance

Hand

Palm

Pallor

Palmer erythemareddening of the palms of the hands

Hand

Flapping tremor(Asterixis)

This motor disorder is characterized by an inability to actively maintain a position. tremor of the hand when the wrist is extended.

Hand

Abdominal Exam

Abdominal Assessment Subjective Data: (Health history questions) Change in appetite Usual weight; Changes in usual weight Difficulty swallowing Are there any foods you have difficulty

tolerating? Have you felt nauseated? Have you vomited

(emesis)?

Abdominal Assessment Experience indigestion? Heart burn (pyrosis) or Belching (eructation) Use antacids, if so, how often Abdomen feel bloated after eating (distension) Abdominal pain? Associated with eating? Alcohol use? Medications?

Abdominal Assessment Bowel habits: Frequency Usual color and consistency Any diarrhea/constipation/ excessive flatulence Any recent change Use of laxatives… Frequency

Abdominal Assessment Past abdominal history: GI problems: ulcer, hepatitis, jaundice,

appendicitis, colitis, hernia Surgical history of abdomen Surgical problems in the past Abdominal x-rays, sonograms, CT results,

colonoscopy results, etc..

Assessment….. Abdomen

a. Skin changes ( color, texture, scars, striae, dilated veins, rashes, and lesions.)

. umbilicus – location and contour

. symmetry

. contour – flat, rounded, distended.

. observable masses – hernias and other masses.. movement – observable peristalsis and pulsation.

Physical Exam Preparation for physical exam: Good lighting, warm room, empty bladder Supine, head on pillow or raised, knees

flexed or on pillow, arms at side Expose abdomen so it is fully visible Enhance relaxation through breathing

exercises, imagery, use of a low/soothing voice and ask pt. to tell about abd. Hx.

Inspection

(7S)Symmetrical & movement with respiration.Scar.Striae.Stoma.Shape of the umbilicus (inverted, flat, exerted).Shape of the flank (full, straight, empty). Skin lesions.

(4P)Prominent veins (caput medusa, SVC obstruction)Pulsation Visible (aortic aneurysm). PeristalsisVisible (NL in thin, intestinal obstruction).Pigmentation (Cullen’s sign, Gery-Turner’s sign)

(1D)Abdominal Distension (fat, fluid, fetus, flatus, faeces).

Physical Exam: InspectionContour: Normal ranges from flat to round.

Symmetry: should be symmetric, note bulging, masses or asymmetry.

Umbilicus: normal is midline, inverted and no discoloration.

Skin: surface normally smooth and even color.

Abdominal contour in healthy person abdomen is usually flat from xiphoid to symphysis pubis , the umbilicus is located in the abdominal center. depending on the nutritional status, the abdominal contour may be lightly protuberant or scaphoid.

Abdominal bulgegeneralized abdominal bulge is usually caused by ascites When the patient is in supine position, the flanks of patient is bulgingsome causes for ascites: heart failure cirrhosis of liver nephrotic syndrome TB peritonitis

Cont,

the other causes of abdominal bulge: include the distention of the bowel with trapped gas, such as intestinal obstruction, massive tumor, obesity

Appearance of the abdomen(Skin)

• Abnormal venous patterns

• Abnormal discoloration

• Umbilicus is sunken .

Striae

• Stretch marks are silvery white linear marked about 1-6cm

In Pregnancy and obese individuals

• Cushing’s syndrome ( purple or blue).

Cullen’s sign

Ecchymosismlocal areas of discoloration about the umbilicus and in the region of the loins, in acute hemorrhagic pancreatitis and other causes of retroperitoneal hemorrhage ( bluish perumblical colour )

Abdominal veins in healthy person abdominal vein can not be seen or can be seen a little in thin person, but not dilated, in patient with obstruction of the portal venous system or in the vena cava,You may find distended veins.

when you find distended veins on the abdomen you should ascertain the direction of flow. the normal direction of flow is away from the umbilicus , that is the upper abdominal veins carry blood up ward to the superior vena cava. And the lower abdominal veins flow downward to the inferior vena cava.

Outward flow pattern from umbilicus in all directions Portal HTN

An aortic aneurysm

• Palpable mass

• Patient feeling of pulsation

• On rare occasions, a lump can be visible.

• Gastric peristalsis is commonly seen in neonates with congenital hypertrophic pyloric stenosis

Visible gastric Peristalsis

Intestinal peristalsis in partial and chronic intestinal obstruction

Colonic obstruction is usually not manifest as visible peristalsis

Visible intestinal Visible intestinal PeristalsisPeristalsis

Visible Peristalsis

Gastric or intestinal pattern and peristalsis in healthy person peristalsis is not visible, but in patient with pyloric or intestinal obstruction you can see peristalsis, in pyloric obstruction on epigastrium the peristalsis is from left costal margin to right, in intestinal obstruction you can see peristalsis around umbilicus the direction of peristalsis is irregular.

Auscultation for bowel sounds

• Normal sounds are due to

peristaltic activity

5- 30 time \min.• peristalsis: A progressive

high pitched gurgeling,cascading sound sound begin with RLQ.

Auscultation for bowel sounds

It is performed before percussion and palpation

Increased or decreased bowel sounds

Normoactive, hypoactive, hyperactive, or absent

Bowel sound abnormalities

• Hyperactive sound :

• Auscultate peristaltic sounds which are normally loud, high pitched

• Hypoactive sound : less than 5 time \min

• Silent abdomen : listen for at least "5" minutes before concluding that no bowel sound (. In case of abdominal surgery,inflammation

Palpation

Before starting palpation, remember:Relax the abdominal muscles.If necessary, ask the patient to bend the knee to relax the muscle.Ask if any particular area is tender and palpate that area last. Look into patient facial expression while palpating the abdomen.

2 Palpation

mainly used in abdominal examination mass: location size contour consistency mobility tenderness pulsation

palpation

The methods of palpation Light palpation Deep Palpation deep slipping palpation bimanual palpation deep press palpation two hand deep palpation

The methods of palpation

light palpation abdominal muscle tensity abdominal tenderness

Deep Palpation deep slipping palpation ---deep mass bimanual palpation ---liver spleen kidney deep press palpation ---tenderness point

bimanual palpation liver and spleen

Intra abdominal masses or enlargements of Intra abdominal masses or enlargements of the liver, gallbladder or spleenthe liver, gallbladder or spleen

They will They will shift downshift down with inspiration and with inspiration and backback with with expiration.expiration. (It will become more (It will become more evident and palpable evident and palpable when patient flexes when patient flexes neck as this contracts neck as this contracts rectus muscles. ).rectus muscles. ).

Standard Method Liver palpation Ask the patient to take a deep breath You may feel the edge of the liver press against your fingers when diaphragm push it down. •Palpating hand is held steady while patient inhales and moved while the patient breathes out

Cont

• Murphy’s Sign- “inspiratory arrest” palpate the liver should be painless but if pain present patient cant complete deep breathing = cholecystitis

Rebound Tenderness- Blumberg’s SignTechnique used for tenderness when abdominal pain reported. Hold your hand 90 degree or appendicular to abdomen done after examination occur normally no pain response after palpation

indication of peritonitis.

Hooking TechniqueAn alternative method of palpating liver is to stand up at person’s shoulder and swivel your body to right so that you face person’s feet•Hook your fingers over costal margin from above. Ask person to take a deep breath•Try to feel liver edge bump your fingertips

Spleen palpation

• Normally spleen is not palpable and must be enlarged three times its normal size to be felt

• (LUQ) Support lower left rib cage with left hand while patient is supine and lift anteriorly on the rib cage normally not palpable must enlarge 3 time

• .

Cont

• It can be palpable in case of (trauma ,leukemia , lymphoma) if it palpated avoid moving it to avoid rapture

You should feel nothing firm

Examination of Kidney

• Patient take a deep breath.

• Feel lower pole of kidney and try to capture it between your hands.

Cont –Kidneys

• Search for right kidney by placing your hands together in a “duck-bill” position at person’s right flank

• Press your two hands together firmly (you need deeper palpation than that used with the liver or spleen) and ask person to take deep breath

• In most people, you will feel no change• Occasionally, you may feel lower pole of right

kidney as a round, smooth mass slide between your fingers

Cont

• Left kidney sits 1 cm higher than right kidney and is not palpable normally

• Search for it by reaching your left hand across abdomen and behind left flank for support

• Push your right hand deep into abdomen and ask person to breathe deeply

• You should feel no change with inhalation

Kidney palpation

• Left kidney sits 1 cm higher than right kidney and is not palpable normally

• Place left hand posteriorly just below the right 12th rib. Lift upwards.

• Palpate deeply with right hand on anterior abdominal wall.

Objective Data (cont.)

• Palpate surface and deep areas (cont.)– Aorta

• palpate for the abdominal aorta to check whether it is expansile, which could be suggestive of an aneurysm. Note that the aortic pulsation can often be felt in thin patients

Slide 21-70

Percussion (technique)Percussion (technique)

Indirect percussion

PERCUSSION

Determine the presence of fluid, distention, and masses. Presence of air – tymphany,

•Assessment technique used to assess size and density of organs in the abdomen

•Examples: used to measure size of liver or spleen

• lightly percussing all 4 quadrants for tympany or dullness

• tympany usually predominates due to gas in the bowel

Percussion Sounds

Resonance DullnessTympany Flatness Hyperresonance

Dullness: This is a short high pitched and is not loud. The sounds heard over liver .

Flatness: Flatness will be present when there is an extensive pleural effusion or over a solid organ such as the liver and heart

ii) Guarding: This is an involuntary reflex contraction of the muscles of the abdominal wall overlying an inflamed

viscus and peritoneum. It produces local rigidity and indicates localised peritonitis. The spasms of the muscle will prevent palpation of the underlying viscus. Guarding is seen for example in acute appendicitis

iii) Rigidity: Gener alised or “boar d like” r igidit y is an indicat ion of gener alised per it onit is. I t is an ext ension of guar ding wit h involvement of all t he muscles of t he abdominal wall.The pat ient may also manif est “rebound tenderness” wher e deep palpat ion is associat ed wit h pain but even mor e pain when t he palpat ing hand is suddenly wit hdr awn.

Sites of Referred Abdominal Pain

Example: Typical pain in Acute appendicitis

Site: poorly localized, periumbilical pain followed usually by RLQ pain

Onset: vagueCharacter: dull periumbilical pain, may be crampingRadiation: periumbilical RLQAssociated factors: anorexia, nausea/vomiting, low feverTiming: Periumbilical (4-6h), RLQ (depends on

intervention)Exacerbating/relieving factors: if subsides temporarily,

suspect perforation of the appendix, movement/cough.Severity: periumbilical (mild but increasing), RUQ

(steady/more severe)

• Liver dull pain in right upper quadrant or epigastric

• Esophagus : GER burrning in midepigastrim or behind lower sternum

• Gallbladder : cholecystitis is biliary colic sudden pain in right upper quadrant , Rt &Lt scapula

• Pancreas: acute boring midepigastrium radiate to back & Lt scapula

• Stomach :dull ,aching,gnawing, epigastric radiate to back or substernal

• Kidney :sudden onset of sever colicky flank or lower abdominal pain

• Small intestine : generalized abd.pain with neasea ,vomiting

• Colon : large bowel sharp, burning obstruction, colicky &cramping

Abnormal Findings:Abdominal Distention

• Obesity

• Air or gas

• Ascites

• Ovarian cyst

• Pregnancy

• Feces

• Tumor

Slide 21-85

Abnormal Findings:On Palpation of Enlarged Organs• Enlarged liver

• Enlarged nodular liver

• Enlarged gallbladder

• Enlarged spleen

• Enlarged kidney

• Aortic aneurysm

Slide 21-86

Ascites• Accumulation of free fluid in peritoneum

• Assessment involve single curve, everted umblicus, bluging flanks ,glistening skin recnt wt. gain

Abdominal distention; dilated veins

Air \ gas: Decrease or absent bowel sound

Percussion : tympany over large area

But feces :inspection :local distentionAuscaltation normal bowel sound Percussion :dullness over fecal mass

Obese abdomen

Tumor localized distention Auscultation normal bowel sound Percussion :dull over mass

Hepatomegaly

ascites

Hernia Soft skin covered

mass ,protrusion intestine trough weakness increased due to increase abdominal pressure

Epigastria , incisional & Diastasis Recti