Assessing The Digestive System: A Guide For Nurses

Assessing the digestive system a guide for nurses Ns. Ahmad Hasyim W, M.Kep, MNg School of nursing Faculty Medicine Brawijaya University

Contents

The essential role of assessment

Assessment techniques

Interpreting the finding

The essential role of assessment • Good quality assessment will assist in: – – – –

Gather important data Pinpoint the core problem Eliminate other possible causes Strong foundation for care planning  diagnoses, planning (intervention and outcome) – Evaluate the patient’s progress

The steps in nursing assessment

The landmark of digestive system

History taking in digestive system Common aspects: • Pain • Dyspepsia • Intestinal Gas • Nausea and Vomiting • Change in Bowel Habits and Stool Characteristics • Appetite or eating patterns • Weight gain or loss

Pain • Identify: The character, duration, pattern, location, distribution

Dyspepsia • Is an upper abdominal discomfort associated with eating (commonly called indigestion). • Sign and symptoms: discomfort, fullness, bloating, early satiety, regurgitation

Intestinal Gas • Appear as belching and/ or flatulence • May indicate food intolerance or gallbladder disease

Nausea and Vomiting • Related conditions: irritation, infections, hepatobiliary or pancreatic disorders, mechanical obstruction, increased intracranial pressure, psychogenic disorder, antitumor chemotherapy medications • The emesis, or vomitus, may vary in color and content and may contain undigested food particles, blood (hematemesis), or bilious material mixed with gastric juices.

Change in Bowel Habits and Stool Characteristics

• Abnormal elimination frequency: increased (diarrhea) or decreased (constipation) • Stool Characteristics: – Black/Dark, red (bright/dark)  melena – Light-gray or clay-colored stool,  decrease or absence of conjugated bilirubin – Stool with mucous threads or pus  infection

Physical assessment of the digestive system

Inspection

Auscultation

Palpation

Percussion

Inspection Visual assessment May use lighter and tongue spatel Area of inspection

Possible finding

Intepretation

Lips and oral cavity

Gum bleeding, abnormal mass, white thrush, stomatitis

Coagulation problem, tumor (benign/malign), immunodeficiency, vitamin deficiency

Abdominal

1. Shape: distended 2. Spider nevi, caput medusa 3. Color: yellowish

1: circulation problem, hypoalbuminemia, abnormal mass 2: increased portal pressure 3: hepatic/biliary problems

Auscultation • Bowel sound (bising usus) – Using the diaphragm  Normal: 5 to 35 per minute  are assessed in all four quadrants – hypoactive (one or two sounds in 2 minutes) – hyperactive (five to six sounds heard in less than 30 seconds) – absent (no sounds in 3 to 5 minutes)

• Vascular sounds – Using the bell of the stethoscope, any bruits in the aortic, renal, iliac, and femoral arteries are noted

• Friction rubs are high-pitched and can be heard over the liver and spleen during respiration

Palpation Aspect of palpation

Possible finding

Interpretation

Pain

Pain on pressure Stiffness

Infection, inflammation

Tenderness

Fluid accumulation

Fluid imbalance

Solid mass

Organ enlargement Tumor Fecal accumulation

Organ palpation

see module

Specific case assessment

Appendicitis Cirrhosis Peritonitis

Percussion Look for: • Percussion sounds • Normal findings: – Tympanic – Except in solid organs: liver, spleen

• Pain – Positive in: internal organ problems (liver, kidney, spleen)