Nursing Assessment: Gastrointestinal System

1. Nursing Assessment: Gastrointestinal System George Ann Daniels, MS, RN

3. Herpes simplex Benign vesicular lesions Candidiasis White curdlike lesions surrounded by erythematorus mucosa yeast

4. Glossitis Reddened, ulcerated swollen tongue Vit B deficiency, irritation, injury, exposure to streptococci

5. Esophagus and Stomach Dysphagia Difficulty swallowing Sensation of food sticking in the esophagus Hematemesis Vomiting of blood Pyrosis Heartburn Dyspepsia Burning pain Eructation Belching Nausea/Vomiting Feeling of or expulsion of gastric contents through the mouth

6. Abdomen Distention Enlarged abdomen Excessive gas accumulation Tympany Ascities Accumulation of fluid within the abdominal cavity Bruit Humming or swishing sound heard through stethoscope over vessels Narrowing of the vessels

7. Boyborygmi Waves of loud, gurgling sound Hyperactive bowel Rebound tenderness Sudden pain when fingers are withdrawn quickly Appendicitis

8. Hernia Bulge or nodule in abdomen Appearing on straining Inguinal, femoral, umbilical, or incisional

9. Rectum and Anus Hemorrhoids Thrombosed veins in rectum and anus Internal or external Tenesmus Painful and ineffective straining at stool Steatorrhea Fatty, frothy, foul smelling stool Floaters

10. Manifestations of GI Dysfunction Anorexia Absence of the desire to eat Weight, dull,thin brittle hair, tired, apathetic facial expression; dry skin and nails; muscle wasting Lab work-malnutrition Albumin < 3.5 g/dL Lymphocyte count < 1500 mm3 Changes in electrolytes NDX Altered Nutrition Altered health maintenance NDX Altered Nutrition Altered health maintenance NDX Altered Nutrition Altered health maintenance

11. Intestinal gas Flatus is gas passed through the rectum Swallowed air, or gas forming foods 0.6 L is passed daily Gas forming foods:HandoutGas forming foods:Handout

12. Bleeding Upper or lower GI tract Acute- >1000mL or discrete of 100mL Chronic over a period of weeks or months Types Occult Melena Hematochezia Retorrhagia Hematemesis Occult- hidden- Guaiac or hemmocult - 3 weeks after bleeding has occurred Melena- black tarry sticky, foul smelling stool- Upper GI or lesions in jejunum or ileum Hematochezia-bloody stools Lower GI bleed- polps, maligency. Blood after the passage of the stool-hemorrhoids Rectorhagia- passage of red blood absence of feces- anorectal disease Hematemesis- vomiting of blood- Upper GI bleed, frank dark red blood, dark red, brown, mahogany, or black. The longer the blood is in the stomach the darker it turns. If clotted in the stomach looks like coffee grounds.Occult- hidden- Guaiac or hemmocult - 3 weeks after bleeding has occurred Melena- black tarry sticky, foul smelling stool- Upper GI or lesions in jejunum or ileum Hematochezia-bloody stools Lower GI bleed- polps, maligency. Blood after the passage of the stool-hemorrhoids Rectorhagia- passage of red blood absence of feces- anorectal disease Hematemesis- vomiting of blood- Upper GI bleed, frank dark red blood, dark red, brown, mahogany, or black. The longer the blood is in the stomach the darker it turns. If clotted in the stomach looks like coffee grounds.

13. Management Assess blood loss VS Systolic B/P < 90=25-50% volume loss HR < 120= 20-25 % loss HCT/HGB IV NS/LR Transfusion TX varies with diagnosis

14. Diagnostic Procedures Gastric Analysis Stomach contents are examined Hydrochloric Acid Occult Blood Malignant cells Bacteria Parasites Preparation Light meal or clear liquids night before NPO after midnight No smoking the morning of test N/G tube Complications- N/V

15. Upper GI series/Barium Swallow Esophagus, stomach, and duodenum bulb Preparation NPO after midnight 8-12 hours No smoking after midnight Upright position behind fluoroscopic screen Swallow Barium Contrast medium Various positions by tilt table Visualize barium passing through GI tract 1-2 hours Post procedure encourage fluids Constipation may occur from barium White stools up to 72 hours Increase fluids Laxative-MOM Elderly consideration Tolerance of prep

16. Barium Enema/ Lower GI Examination of rectum and colon Tumors, polyps, diverticula, filling defects associated with Crohn�s and ulcerative colitis. Preparation Bowel prep Day before Tape water enema�s till clear Oral cathartic GoLytely Clear Liquid evening meal NPO 8 + hours

17. Day of procedure Suppository or enema Barium instilled into large intestines through the rectum patient is placed in different positions patient then expels barium, further pictures are taken Cramps and urge to defecate Post Oral cathartic, oil retention enema, laxative, suppository Remove residual barium Stools will be white

18. Oral Cholecystogram Visualization of GB for GB disease /stones 1 hour Allergy to iodine and shelfish Preparation Fat free diet night before Ingestion of radiopaque dye tablets at 7 PM Calculation is based on body weight of client NPO after midnight May take two days of dye

19. Day of procedure Films are taken If gallstones are seen the fatty diet is held Fatty diet given Stimulation of GB Further films are taken Complication Diarrhea and vomiting Allergy to iodine

20. Endoscopy Visualization of the Upper and lower GI tract by fiberopitc tube EGD Esophagogastroduodenoscopy Esophagus, stomach, duodenum Fiberoptic tube passing through the mouth

21. Hiatus hernia, esophageal varcies, esophagitis, ulcer disease, polyps, strictures, malignant tumors, biopsy specimens

22. Preparation NPO for 8 hours Consent Sedative for anxiety Versed, diaxapam Patient will be sedated during procedure Throat anesthetized with oral anesthetic Diminished gag reflex Lateral recumbent position Instructed to swallow as tube is advanced Must lie still during procedure Post procedure NPO until gag reflex returns Assess for return of gag reflex (1-2 H)

23. Vital signs including temperature Q 15-30 minutes for 1-2 hours Sudden spike in temperature may indicate perforation Complication Aspiration, bleeding from trauma, infection, and pain Sore throat Warm saline gargle

24. Colonoscopy Visualization of the large intestines to the ileocecal value by fiberoptic tube via rectum Undiagnosed constipation/diarrhea, anorexia, persistent rectal bleeding, lower abd pain, recurring polyps and tumors.

25. Preparation NPO- 8 hours Laxative for 1-3 days prior Night before enema Golyte 8 0z Q 10 minutes Morning of Clear liquids Procedure Sedative ( Valium) Left sims

26. Post procedure Cramps Due to inflation of colon with air Vital signs Observe for rectal bleeding, abdominal distention, Tenesmus