gi system assessment

GASTROINTESTINAL SYSTEMASSESSMENT

PYRAMID POINTSTechnique for abdominal assessmentAssessment of risk factors associated with

gastrointestinal (GI) disordersPreprocedure and postprocedure

interventions for diagnostic studiesCommon laboratory studies related to the

gastrointestinal tract and their relationship to gastrointestinal disorders

RISK FACTORS OF GI DISORDERSFamily history of GI disordersChronic laxative useTobacco useChronic alcohol useChronic high stress levelsAllergic reactions to food or medications Chronic use of aspirin or nonsteroidal

antiinflammatory drugs (NSAIDs)

RISK FACTORS OF GI DISORDERSLong-term GI conditions such as ulcerative

colitis may predispose to colorectal cancerPrevious abdominal surgery or trauma may

lead to adhesionsNeurological disorders can impair movement,

particularly with chewing and swallowingCardiac, respiratory, and endocrine disorders

may lead to constipationDiabetes mellitus may predispose to oral

candida infections

UPPER GI TRACT STUDY (BARIUM SWALLOW)

From Zakus SM: Clinical procedures for medical assistants, ed. 3, St. Louis, 1995, Mosby.

UPPER GI TRACT STUDY (BARIUM SWALLOW)POSTPROCEDURE

A laxative may be prescribed Instruct the client to increase oral fluids to

help pass the bariumMonitor stools for the passage of barium

(stools will appear chalky white) because barium can cause a bowel obstruction

LOWER GI TRACT STUDY (BARIUM ENEMA)

DESCRIPTIONA fluoroscopic and radiographic examination of

the large intestine after rectal instillation of barium sulfate

May be done with or without air

LOWER GI TRACT STUDY (BARIUM ENEMA)

From Heuman DM, Mills AS, McGuire HH: Gastroenterology, Philadelphia, 1997, W.B. Saunders.

LOWER GI TRACT STUDY (BARIUM ENEMA)PREPROCEDURE

A low-residue diet for 1 to 2 days prior to the test

A clear liquid diet and a laxative the evening before the test

NPO after midnight prior to the day of the testCleansing enemas on the morning of the test

LOWER GI TRACT STUDY (BARIUM ENEMA)POSTPROCEDURE

Instruct the client to increase oral fluids to help pass the barium

Administer a mild laxative as prescribed to facilitate emptying of the barium

Monitor stools for the passage of bariumNotify the physician if a bowel movement does

not occur within 2 days

GASTRIC ANALYSIS

DESCRIPTION The passage of a nasogastric (NG) tube into

the stomach to aspirate gastric contents for the analysis of acidity (pH), appearance, and volume; the entire gastric contents are aspirated and then specimens are collected every 15 minutes for 1 hour

Histamine or pentagastrin may be administered subcutaneously to stimulate gastric secretions; may produce a flushed feeling

GASTRIC ANALYSIS

DESCRIPTION Esophageal reflux of gastric acid may be

performed by ambulatory pH monitoring; a probe is placed just above the lower esophageal sphincter, is connected to an external recording device, and provides a computer analysis and graphic display of results

MANOMETRY TUBES AND pH PROBE

From Beare, P. & Myers, J. (1998). Adult health nursing, ed 3, St Louis: Mosby.

GASTRIC ANALYSIS

PREPROCEDUREFasting for 8 to 12 hours prior to the testAvoid tobacco and chewing gum for 6 hours

prior to the testMedications that stimulate gastric secretions

are withheld for 24 to 48 hoursPOSTPROCEDURE

May resume normal activitiesRefrigerate gastric samples if not tested within

4 hours

UPPER GI FIBEROSCOPY

DESCRIPTIONAlso known as esophagogastroduodenoscopy

(EGD)Following sedation, an endoscope is passed

down the esophagus to view the gastric wall, sphincters, and duodenum; tissue specimens can be obtained

ESOPHAGOGASTRODUODENOSCOPY

From Ignatavicius, D. & Workman, M. (2002). Medical-surgical nursing: Critical thinking for collaborative care, ed 4, Philadelphia: W.B. Saunders.


PREPROCEDURENPO for 6 to 12 hours prior to the testA local anesthetic (spray or gargle) is

administered along with midazolam (Versed) IV (provides conscious sedation and relieves anxiety) just before the scope is inserted

Atropine may be administered to reduce secretions, and glucagon may be administered to relax smooth muscle


PREPROCEDUREClient is positioned on the left side to facilitate

saliva drainage and to provide easy access of the endoscope

Airway patency is monitored during the test and pulse oximetry is used to monitor oxygen saturation; emergency equipment should be readily available


POSTPROCEDURENPO until the gag reflex returns (1 to 2 hours)Monitor for signs of perforation (pain,

bleeding, unusual difficulty swallowing, elevated temperature)

Maintain bed rest for the sedated client until alert

Lozenges, saline gargles, or oral analgesics can relieve minor sore throat after the gag reflex returns

ANOSCOPY, PROCTOSCOPY, AND SIGMOIDOSCOPY

ANOSCOPYUse of a rigid scope to examine the anal canal;

client is placed in the knee-chest position with the back inclined at a 45-degree angle

PROCTOSCOPY AND SIGMOIDOSCOPYUse of a flexible scope to examine the rectum

and sigmoid colon; client is placed on the left side with the right leg bent and placed anteriorly

Biopsies and polypectomies can be performed

ANOSCOPY, PROCTOSCOPY, AND SIGMOIDOSCOPY

PREPROCEDUREEnemas until the returns are clear

POSTPROCEDUREMonitor for rectal bleeding and signs of

perforation

FIBEROPTIC COLONOSCOPYDESCRIPTION

A fiberoptic endoscopy study in which the lining of the large intestine is visually examined; biopsies and polypectomies can be performed

Cardiac and respiratory function is monitored continuously during the test

Performed with the client lying on the left side with the knees drawn up to the chest; position may be changed during the test to facilitate passing of the scope

FIBEROPTIC COLONOSCOPY

From Chabner D: The Language of Medicine, ed. 6, Philadelphia, 2001, W.B. Saunders.

FIBEROPTIC COLONOSCOPYPREPROCEDURE

Adequate cleansing of the colon is necessaryA clear liquid diet is started at noon on the day

before the testConsult with the physician regarding medications

that must be withheld prior to the testClient is NPO after midnight on the day before the

testMidazolam (Versed) IV is administered to provide

sedationGlucagon may be administered to relax smooth

muscle

FIBEROPTIC COLONOSCOPYPOSTPROCEDURE

Provide bed rest until alertMonitor for signs of perforationInstruct the client to report any bleeding to the

physician

LAPAROSCOPY (PERITONEOSCOPY)DESCRIPTION

Performed with a fiberoscopic laparoscope that allows direct visualization of organs and structures within the abdomen

Biopsies may be obtained

LAPAROSCOPY: PLACEMENT OF TROCARS

From Chabner D: The Language of Medicine, ed. 6, Philadelphia, 2001, W.B. Saunders.

CHOLECYSTOGRAPHY

DESCRIPTIONPerformed to detect gallstones and to assess

the ability of the gallbladder to fill, concentrate its contents, contract, and empty

CHOLECYSTOGRAPHY

PREPROCEDUREAssess allergies to iodine or seafoodContrast agents are administered 10 to 12

hours (evening before) before the testClient is NPO after the contrast agent is

administeredInstruct the client that if a rash, itching, hives,

or difficulty breathing occurs after taking the contrast agent, to report to the emergency room

CHOLECYSTOGRAPHY

POSTPROCEDUREInform the client that dysuria is common

because the contrast agent is excreted in the urine

A normal diet may be resumed (a fatty meal may enhance excretion of the contrast agent)

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY (ERCP)

DESCRIPTIONExamination of the hepatobiliary system via a

flexible endoscope inserted into the esophagus to the descending duodenum; multiple positions are required during the procedure to pass the endoscope

If medication is administered prior to the procedure, the client is monitored closely for signs of respiratory and central nervous system depression, hypotension, oversedation, and vomiting


PREPROCEDUREClient is NPO for several hours prior to the

procedureSedation is administered prior to the

procedure POSTPROCEDURE

Monitor vital signsMonitor for the return of the gag reflexMonitor for signs of perforation or infection

PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY

DESCRIPTIONInvolves the injection of dye directly into the

biliary treeThe hepatic ducts within the liver, the entire

length of the common bile duct, the cystic duct, and the gallbladder are clearly outlined


PREPROCEDUREClient is NPOSedating medication is administered

POSTPROCEDUREMonitor vital signsMonitor for signs of bleeding, peritonitis, and

septicemia; report the presence of pain immediately

Administer antibiotics as prescribed to reduce the risk of sepsis

PARACENTESIS

DESCRIPTIONTransabdominal removal of fluid from the

peritoneal cavity for analysis

PARACENTESIS


PARACENTESIS

PREPROCEDUREObtain informed consentVoid prior to the start of procedure to empty

bladder and to move bladder out of the way of the paracentesis needle

Measure abdominal girth, weight, and baseline vital signs

Note that the client is positioned upright on the edge of the bed with the back supported and the feet resting on a stool (Fowler’s position is used for the client confined to bed)

PARACENTESIS

POSTPROCEDURE Monitor vital signsMeasure fluid collected, describe, and recordLabel fluid samples and send to the laboratory

for analysisApply a dry sterile dressing to the insertion

site; monitor site for bleedingMeasure abdominal girth and weight

PARACENTESIS

POSTPROCEDURE Monitor for hypovolemia, electrolyte loss,

mental status changes, or encephalopathyMonitor for hematuria due to bladder traumaInstruct the client to notify the physician if the

urine becomes bloody, pink, or red

LIVER BIOPSY

DESCRIPTIONA needle is inserted through the abdominal

wall to the liver to obtain a tissue sample for biopsy and microscopic examination

LIVER BIOPSY

From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes, ed 6, Philadelphia: W.B. Saunders.

LIVER BIOPSY

PREPROCEDUREObtain informed consentAssess results of coagulation tests

(prothrombin time, partial thromboplastin time, platelet count)

Administer a sedative as prescribedNote that the client is placed in the supine or

left lateral position during the procedure to expose the right side of the upper abdomen

LIVER BIOPSY

POSTPROCEDUREAssess vital signs Assess biopsy site for bleedingMonitor for peritonitisMaintain bed rest for several hoursPlace client on the right side with a pillow

under the costal margin to decrease the risk of hemorrhage, and instruct the client to avoid coughing and straining

Instruct the client to avoid heavy lifting and strenuous exercise for 1 week

GI MOTILITY STUDIESRADIONUCLIDE TESTING

Assesses gastric emptying and colonic emptying time

A capsule containing radioactive material is administered to the client and the time it takes for the radioactive material to move through the colon indicates colonic motility

ELECTROGASTROGRAPHYUsed to detect motor or neurological

dysfunction in the stomach; records gastric electrical activity

GI MOTILITY STUDIESESOPHAGEAL MANOMETRY

Detects motility disorders of the esophagus and lower esophageal sphincter

Client is NPO for 8 to 12 hours before the test and medications that affect GI motility are withheld

GASTROINTESTINAL, SMALL INTESTINAL, AND COLONIC MANOMETRY Evaluates delayed gastric emptying and gastric

and intestinal motility disorders; often is an ambulatory outpatient procedure that lasts 24 to 72 hours

GI MOTILITY STUDIESANORECTAL MANOMETRY

Measures the resting tone and contractibility of the anal sphincters to evaluate the client with chronic constipation or fecal incontinence; phosphosoda or a cleansing enema is administered 1 hour prior to the test

RECTAL SENSORY FUNCTION TESTEvaluates rectal sensory function and

neuropathy to evaluate the client with chronic constipation, diarrhea, or incontinence

DEFECOGRAPHYMeasures anorectal functionThick barium is instilled into the rectum,

fluoroscopy is performed, and the function of the rectum and anal sphincter is visualized while the client attempts to pass the barium

Digital subtraction methods may be used for more rapid imaging and mapping of rectal evacuation

No preparation is required

STOOL SPECIMENSIncludes inspecting the specimen for

consistency and color and testing for occult blood

Tests for fecal urobilinogen, fat, nitrogen, parasites, pathogens, food substances, and other substances; these tests require that the specimen be sent to the laboratory

Random specimens are promptly sent to the laboratory

STOOL SPECIMENSQuantitative 24- to 72-hour collections must

be kept refrigerated until they are taken to the laboratory

Some specimens require that a certain diet be followed or that certain medications be withheld; check agency guidelines regarding specific procedures

HYDROGEN BREATH TEST

Evaluates carbohydrate absorption by determining the amount of hydrogen expelled in the breath after it is produced in the colon and absorbed in the blood

Used to aid in the diagnosis of bacterial overgrowth in the intestine

UREA BREATH TEST

Detects the presence of Helicobacter pylori, the bacteria that causes peptic ulcer disease

The client consumes a capsule of carbon-labeled urea and provides a breath sample 10 to 20 minutes later

UREA BREATH TESTClient is instructed to avoid antibiotics or

bismuth subsalicylate (Pepto-Bismol) for 1 month before the test; sucralfate (Carafate) and omeprazole (Prilosec) for 1 week before the test; and cimetidine (Tagamet), famotidine (Pepcid), ranitidine (Zantac), or nizatidine (Axid) for 24 hours before breath testing

Helicobacter pylori can also be detected by assessing serum antibody levels

LIVER AND PANCREAS LABORATORY STUDIES

ALKALINE PHOSPHATASEReleased during liver damage or biliary

obstructionPROTHROMBIN TIME (PT)

Prolonged with liver damageSERUM AMMONIA

Assesses the ability of the liver to deaminate protein by-products

LIVER ENZYMES (TRANSAMINASE STUDIES)Elevated with liver damage

LIVER AND PANCREAS LABORATORY STUDIESCHOLESTEROL

Increase indicates pancreatitis or biliary obstruction

BILIRUBINIncrease indicates liver damage or biliary

obstruction

AMYLASE AND LIPASEElevations indicate pancreatitis

Refer to module entitled Laboratory Values for information regarding normal liver and pancreas laboratory levels

ABDOMINAL ASSESSMENT

Inspect skin for color, abnormalities, contour, and tautness, and the abdomen for distension

Auscultate for bowel soundsPercuss for air or solidsPalpate for tenderness

SYSTEMATIC ROUTE FOR ABDOMINAL PERCUSSION


ASSESSMENT FOR BOWEL SOUNDS

Auscultate bowel sounds before percussion and palpation

Normal bowel sounds occur 5 to 30 times a minute or every 5 to 15 seconds

Auscultate in all abdominal quadrantsListen at least 5 minutes in each quadrant

before assuming sounds are absent

QUADRANTS OF THE ABDOMEN

From Black, J., Hawks, J., & Keene, A. (2001). Medical-surgical nursing: Clinical management for positive outcomes, ed 6, Philadelphia: W.B. Saunders.

gi system assessment

Documents

hours y postprocedure

prescribed y

passage of barium y

test y npo

test y medications

hours y monitor

sigmoidoscopy y use

swallowing y cardiac