GASTROINTESTINAL ASSESSMENT

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ANATOMYAbdomen

ANATOMY AND PHYSIOLOGY Abdominal Landmarks:

Abdominal wall is divided into four quadrants by a vertical and a horizontal line bisecting at the umbilicus

NINE ABDOMINAL REGIONS

MATCH THE ORGANS!Word Bank• Spleen• Stomach• Liver• Cecum• Gallbladder• Sigmoid Colon• Bladder• Descending

colon• Ascending colon• Appendix• Small Intestine• Pubic

Symphysis

ORGANS PER QUADRANT

Liver Gallbladder Duodenum Head of pancreas Right kidney and

adrenal gland Hepatic flexure of

colon Part of ascending

and transverse colon

Stomach Spleen Left lobe of liver Body of pancreas Left kidney and

adrenal gland Splenic flexure of

colon Part of transverse

and descending colon

Right Upper Quadrant Left Upper Quadrant

ORGANS PER QUADRANT

Cecum Appendix Right ovary and

tube Right ureter Right spermatic

cord

Part of descending colon

Sigmoid colon Left ovary and tube Left ureter Left spermatic cord

Right Lower Quadrant Left Lower Quadrant

ASSESSMENTGastrointestinal

SUBJECTIVE ASSESSMENT Changes in appetite? Dysphagia? Food intolerance? Abdominal pain? Nausea/vomiting? Bowel Habits?

Diarrhea or constipation? Changes in weight? Past abdominal history? Last bowel movement? Nutritional assessment Medication reconciliation

OBJECTIVE ASSESSMENTExamination Order:

InspectAuscultatePercussPalpate

Why is the order of assessment techniques different?

ANSWERDuring the physical examination of the abdomen, auscultation is performed prior to percussion or palpation because those techniques can increase peristalsis, providing a false interpretation of bowel sounds

INSPECTION Position the patient supine with the head on a

pillow Ensure patient has emptied his or her bladder

Demeanor: Benign facial expression Slow, even respirations Free from restlessness or absolute stillness

INSPECTION Skin color, scars, or lesions

Should appear smooth, even color. A common pigment variation is striae (stretch marks).

Silvery, white jagged marks 1-6cm long. Occurs following rapid or prolonged stretching, as in

pregnancy or excessive weight gain.

Hair distribution Pubic hair: Diamond shaped in adult males; inverted

triangle in females

INSPECTION Symmetry:

Bilateral symmetry upon both inspiration and expiration, free from bulging or masses, which can be identified by shadows

Umbilicus: Midline, inverted without discoloration, inflammation, or hernia.

Contour: Examine the contour of the abdomen from the rib margin to the pubic bone. Should range from flat to rounded

INSPECTION Pulsations or Movement:

Aortic pulsation in the epigastric area Particularly in thin people with good muscle wall

relaxation

Respiratory movement Particularly in males

Peristalsis Slow waves ripple across the abdomen

AUSCULTATION Bowel sounds are caused

by the movement of air and fluid through the small intestine

Begin listening at the: RIGHT LOWER QUADRANT

(RLQ)This is the ileocecal valve area and bowel sounds are always present here, normally.

BOWEL SOUNDS AUSCULTATION Bowel sounds are high pitched, gurgling, with

irregular occurrence between to 5-30 times a minute

Hyperactive: Greater than 30/minute Normative: Between 5-30/minute Hypoactive: Less than 5/min Hyerperistalsis: (growling stomach),

Borborygmus

To say no bowel sounds are present, one much auscultate for a FULL FIVE minutes. A perfectly “silent” abdomen is uncommon. http://evolvels.elsevier.com/section/default.asp?id=2259_global_0001&m

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AUSCULTATION OF VASCULAR SOUNDS Auscultate for vascular sounds or bruits,

especially in the patient with hypertension

Use firmer pressure over the aorta, renal arteries, iliac, and femoral arteries

Generally NOT present

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AUSCULTATION OF VASCULAR SOUNDS

PERCUSSION Why?

Assess density of abdominal contents Locate organs Screen for abnormal fluid or masses

Expected findings: Tympany: Over majority of the abdomen due to

air rising to the surface when the patient is supine

Dullness: Occurs over organs (liver), distended bladder, adipose tissue, fluid, or a mass

Hyperresonance: Present with gaseous distention

PERCUSSION

PERCUSSING THE LIVER 1). Measure liver height:

Start at the right midclavicular line: Percuss in the area of lung resonance Percuss down the interspaces until the sound changes to a

dull quality Mark the spot of change

(generally the 5th intercostal space) 2). Then,

Percuss abdominal tympany Percuss UP along the midclavicular line Mark where the sound changes from tympany to dull

3). Finally, Measure the distance between the two marks. Generally, the

liver span ranges between 6-12cm, correlating with height.

Hepatomegaly: Enlargement of the liver

FIST PERCUSSION: CVA TENDERNESS CVA: Costovertebral Angle Tenderness Patient should be sitting up (90’), stand

behind to perform percussion.

Process: Place one hand over the 12th rib at the

costovertebral angle of the back. Thump that hand with the ulnar edge of your

other fist Generally, patient will feel a thump, but no pain.

Sharp pain indicates inflammation of the kidney or pananephric area (near the kidney).

FLUID WAVE Used when ascites

is suspected

How: Place patient’s hand

firmly on the abdominal midline

Place left hand on patient’s right flank

Using right hand, give the left flank a firm strike

If ascites is present, a distinct tap will be felt on your left hand

PALPATION

Watch for:Muscle guardingRigidityLarge massesTenderness

Why palpate?• Assess the size, location, and consistency of organs• Screen for abnormal masses or tenderness

PALPATION Types of Palpation:

Light palpation: Keep four fingers together, depress skin lightly by approximately 1cm

Deep palpation: Press down 5-8cm. Bimanual palpation: Using two hands, the bottom hand

senses, while the top pushes. Used with the large or obese abdomen.

How: Have the patient lay supine with knee’s slightly bent Place the palpating hand low and parallel to the

abdomen Palpate to desired depth with four fingers together Make a gentle, rotary motion Move clockwise, lifting fingers completely off the skin Save palpation of tender areas until last

BIMANUAL PALPATION

PALPATION: ABNORMAL FINDINGS If you identify a mass, distinguish from a

normally palpable structure or enlarge organ: Note:

Location Size Shape Consistency (soft, firm, hard) Surface (smooth, nodular) Mobility (including with respirations) Pulsatility Tenderness

AORTIC PULSATION Using opposing

thumb and fingers, palpate the aortic pulsation

Location: Upper abdomen, left of midline

Generally 2.5-4cm, anterior pulsation

ASSESSING REBOUND TENDERNESS Also known as Blumberg’s Sign Used when patient:

reports abdominal pain reports tenderness during palpation

How: Perform at the end of assessment Select a location away from reported pain Hold hand 90’ to abdomen Push into abdomen slowly and deeply Lift hand up quickly

Response: No pain on release of pressure: Expected Pain: sign of peritoneal inflammation, possible appendicitis

AGE RELATED VARIATIONS Infant

Diastasis recti: Separation of rectus muscles with a visible bulge along the midline. Most common with black infants, disappears by early childhood

Child Protuberant abdomen: When supine and

standing, children under age 4; flat when supine after age 4

Movement with respirations: Until age 7

AGE RELATED VARIATIONS Older adult

Subcutaneous fat on abdomen and hips Liver is easier to palpate due to decreased

abdominal muscle tone Liver location is palpated 1-2cm below costal

margin upon inhalation

Sample Documentation

ANUS, RECTUM & PROSTATEAnatomy & Physiology

STRUCTURE & FUNCTION Anus:

The outlet of the gastrointestinal tract 3.8cm long Has two sphincters:

Internal: Involuntary External: Voluntary

Rectum: Distal portion of the large intestine 12cm long; from sigmoid colon, 3rd sacral vertebra

STRUCTURE & FUNCTION For Him:

Prostate: Lies in front of the anterior wall of the rectum Secrets thin, milky alkaline fluid that helps sperm

viability

For Her: Uterine Cervix: Lies in front of the anterior wall, may be palpated

through it

ANUS, RECTUM & PROSTATEThe Assessment

SUBJECTIVE Usual bowel routine? Change in bowel habits? Rectal bleeding, blood in

stool? Self-care behaviors Family history Rectal conditions:

Itching Hemorrhoids Fissure Fistula

Medications

OBJECTIVE ASSESSMENT Inspection:

Color: Moist, more pigmented skin than perianal skin

Surface characteristics: Coarse folded skin

Hair: None

Hemorrhoids: Flabby skin sac; shiny blue skin sac: thrombosed hemorrhoid

Dimpling, inflammation, swelling, hair tuft, or tenderness at the tip of coccyx may indicate pilonidal cyst (resulting from inflammation from ingrown hair, debris)

Lesions: Abnormal finding with inflammation; document location using

12hour clock method.

Positioning: Females:

Left lateral decubitus Lithotomy (if

examining genitalia too)

Males: left lateral decubitus standing

OBJECTIVE ASSESSMENT

OBJECTIVE ASSESSMENT Palpation:

Gloves! Lubricating jelly. Explain what you are doing!

1) Place the pad of index finger gently against anal verge

2) Feel for the tightening of sphincter, then relaxation; as it relaxes, flex the tip of your finger and insert slowly in the direction of the umbilicus

3) NEVER use 90’ angle!

OBJECTIVE ASSESSMENT4) Rotate your examining finger,

palpate entire muscular ring*assess sphincter tone

5) Canal should feel smooth and even

6) Ask person to tighten evenly around finger

7) Bidigital palpation: Use thumb against the perianal tissue. Press examining finger; assess swelling or tenderness.

Also, assesses bulbourethral glands

*Cowper’s glands, in males only

STOOL ASSESSMENT Occult Blood

Test may vary by agency or institution.

Positive is an abnormal finding

False-positive may be caused after eating large amounts of red-meat in past 3 days

AGE & SITUATIONAL VARIATIONS

Newborns: Visual inspection of anus Confirm patent rectum with meconium passing

Meconium: greenish stool passed the first 24-48hrs after birth Infants & Children:

Buttocks should be firm and rounded, no masses or lesions Meningocele Mongolian spots Diaper rash

Omit palpation unless symptoms warrant If necessary: child on back, legs flexed- use fifth finger due to

size

HEALTH PROMOTION After age 50…

Colorectal screening: Digital rectal exam annually Fecal occult blood test annually Sigmoidoscopy every 5 years Colonscopy every 10 years

Prostate cancer screening:After age 45 in black males; after age 50 all others Prostate-specific antigen (PSA) annually

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