36 terms

Focal GI/GU Assessment

WEEK 6 - 2/24/10 - Lab Material covers Lab lectures, notes, PowerPoints, readings, Online modules
Small Intestines Gallbladder Stomach Color Bladder ABDOMINAL WALL (4 quadrants)
GI/GU Assessment - Present Health Status
DEVELOP a caring, open communication & relationship w/ pt as GI/GU questions can cause embarrasment. ASK: Overall Health, Past Medical History (concerning GI/GU disorders - GERD, surgeries, diverticulities, kidney stones, incontinence); Family History (Renal disease, diabetes); Stress/Chronic Illness; Eating patterns (food & fluids) (may require a 24hr diet recall); Rx/Smoking/ETOH, PQRST
GI/GU Assessment - Past Medical History
*ASK about Abdominal Problems (Ulcers; Colities; Hepatitis; Pancreatitis; Cancer) Family History
GI/GU Assessment - Health History
QUESTIONS about: Appetitie, Dysphagia, Food Intolerance, Abdominal Pain, Nausea/Vomiting, Bowel Habits, Past Abdominal History; Rx; Nutritional Assessment; 24 hr Diet Recall. *PROBLEM BASED: Elimination (bowel); Abdonimal pain/distention; Last BM/Normal pattern; Urination (pain, burning, pattern, color); Pain (back/kidney pain, hist. of stones); Female (LMP, pregnancies, BSE, PAP); Male (TSE)
GI/GU Physical Exam - Objective Data
PREPARATION: Lighting & draping; Measures to enhance abdominal wall relaxation; VOID PRIOR to exam; Exam painful areas LAST. EQUIP: stethoscope. (PT WILL LAY IN SUPINE POSITION UNLESS THERE IS A RISK FOR ASPIRATION, MUSCULOSKELETAL OR PULMONARY PROBLEMS - May put pt at a 30-degree angle) **EXAM ORDER: Inspect then Listen then Palpate
Abdominal Assessment - Inspection
*CHECK: Contour & Symmetry (slightly rounded); Umbilicus (discharge, masses, protrusion) Hernias cause upward protrusion; Skin (rashes, scars, stretch marks, bruising); Pulsation or Movement (visible pulsations = abnormal) Pulsations in epigastric area may be visible on a very thin pt.
Abdominal Distension
(REMEMBER THE 7 F's) --> Fat, Fetus, Fluid, Flatulence, Feces, Fibroid tumor, Fatal tumor
Abdominal Assessment - Auscultation
BOWEL SOUNDS: Divide abdomen into 4 quads. & listen to all 4 (START IN THE RLQ - Loudest!) SOUNDS:Originate from air & fluid through the small intestine. Usually heard w/in 5-30 secs. *IF NO SOUNDS ARE HEARD:listen to all 4 quads. for 5 minutes ea. (Document: BS absent): MAY HEAR A BLOWING SOUNDS:DON'T PALPATE. Auscultate in the epigastric region. No Vascular sounds should be heard over aorta (midline through th abdomen) or femoral arteries (Lower quads)
Bowel Sounds - Hyperactive
*HYPERACTIVE: Heard as "Stomach growling" - LOUD!, High-Pitched, Rushing, Tinkling sound taht signal increased motility. May occur w/ early bowel obstruction, astroenteritis, brisk diarrhea, laxative use & subsiding paralytic ileus.
Bowel Sounds - Hypoactive
*HYPOACTIVE or ABSENT: Heard less frequently. Sound follow abdominal surgery or in bowel obstruction.
Vascular Sounds - Bruits
Indicates narrowing of the major blood vessels & disruption of blood flow.
Abdominal Assessment - Percussion
(Not usually performed unless abdomen is distended) Light tapping Tympany=gas *Dullness=solid (mass) or fluid (ascites)
Abdominal Assessment - Palpation
Light Palpation: (No deeper than 1cm) (Finger pads in circular motion) ASSESS FOR: Tenderness or pain, Flank pain (kidney), bladder distension, Masses, lump, irregularities, Muscle tone, Muscle guarding. *PALPATE TENDER OR PAINFUL AREAS LAST.
Palpation - Rebound Tenderness
Tenderness when pressure is REMOVED or RELIEVED. (Push down slowly and deeply; then lift up quickly)
Palpation - Fluid Wave
(for ascites) POSITIVE FLUID WAVE occurs w/ large amounts of ascitic fluid. ASCITES occur w/ heart failure, portal hypertension, Cirrhosis, Hepatitis, Pancreatitis & Cancer.
Palpation - Bimanual Technique
*LARGE/OBESE ABDOMEN (use bimanual technique) - Use 2 hands on top of ea.other. Top hand does the pushing; bottom hand is relaxed & concentrates on palpation.
GI/GU Lifespan Considerations
*Changes of AGING: Peristalsis SLOWS (risk for constipation), Esophagus dilated (risk for hiatal hernia), Gastric secretions DECREASE (risk for impaired digestion), Degeneration of gastric mucosa (Less protection, decreased intrinsic factor), Increased deposit of subcutaneous fat, Abdominal musculature is thinner/less tone, Organs will be easier to palpate, Bacterial flora less active (risk for impaired digestion, food intolerance), Liver decreases in size & function (55-60%)(reduced storage & synthesizing, Drugs/alcohol metabolize slower); Diminished taste
GI/GU Health Promotion
High FIber Diet; Avoidance of smoking, drug abuse & extensive ETOH use; SIGNS of potential problems (pain, rectal bleeding)
GI/GU - Nursing Diagnoses
PAIN r/t increased gastric acidity, esophageal reflux, and excess production of gas. CONSTIPATION r/t poor fiber diet, lack of exercise & poor water consumption *FLUID VOLUME DEFICIT r/t excessive vomiting or inadequate fluid intake s/t nausea.
Fecal impaction is the inability to pass a hard collection of stool. GREATER RISK: Physically & mentally incapacitated & institutionalized older pts. SYMPTOMS: Constipation, Rectal discomfort, Anorexia, Nausea/Vomiting, Abdominal pain, Diarreah (seeps around impacted stool), Urinary frequency *DIGITAL REMOVAL MAY BE NECESSARY.
*CAUSES: Antibiotic use (alter normal flora in GI tract), Enteral nutrition, Food allergies/Intolerances increase peristalsis and cause diarrhea, Disease, Surgeries, or Diagnostic Testing of the lower GI tract can cause diarrhea.
Procedure that involves the instillation of a specific solution into the rectum and sigmoid colon in an effort to treat constipation or to prepare the client for a diagnostic procedure or abdominal surgery.
Enema - Cleansing
Used for the complete evacuation of feces from the colon. Cleansing enemas require LARGE AMOUNTS of FLUID & RELY on PERISTALTIC STIMULATION TO BE EFFECTIVE
Enema - Oil-Retension
Oil in th solution lubricates the rectum and colon. Feces will also absorb the oil, thereby making it softer and easier to pass.
Enema - Medicated
Solutions contain pharmacologic agents that can be prescribed to treat teh bowel or to decrease the levels of certain electrolytes. EXAMPLE: a medication (Kayexalate) which uses an ion-exchange mechanism to lower critically high potassium levels.
Enema - Hypotonic
CONTENTS: tap water. USED: to soften stool. AGE: Adults COMMENTS:should only be administered once, Overuse can lead to toxicity & circulatory overload
Enema - Isotonic
CONTENTS:Normal saline. USED: to stimulate peristalsis, Soften stool. AGE:Infants & children. COMMENTS: Safest type of solution for infants & children.
Enema - Hypertonic
CONTENTS:commercially prepared solutions (120-180 mL). USED:for pts unable to tolerate large amounts of fluid. AGE:adults & children. COMMENTS:fluid is drawn INTO the colon. NEVER use adult dose for children.
Enema - Soap Suds (SSE)
CONTENTS:up to 1000 mL tap water or normal saline w/ 5 mL CSTILE soap. USED:to irritate the bowel, dilates the colon. AGE:adults. COMMENTS: Solution chosen depends on the pt's condition.
Enema - Oil Retention
CONTENTS:cottonseed or mineral oil in solution. USES: stool absorbs oil & softens for evacuation AGE:adults. COMMENTS:small volume administration.
Enema - Carminative (MGW)
CONTENTS: Magnesium (30mL), Glycerin (60mL), Water (90mL). USE:Relieves gaseous distention. AGE:adults. COMMENTS: Known as MGW enema.
Bladder Diversions
2 CATEGORIES: Incontinent (pts who have an incontinent diversion are unable to control urination and therefore must wear an external urinary ostomy pouch) - INCLUDES: Ileal conduit and Ureterostomy. Continent (pts who have continent diversions such as the Kock or Indiana Pouch over their urinary stoma)
Bowel Diversions
An ENTEROSTOMY is any surgical procedure that produces an articfical STOMA in a portion of intestine through the abdominal wall. SURGICAL OPENINGS: created in the ileum (ileostomy) or colon (colostomy). LOCATION: determines consistency of stool passed or effluent passed.
Loop Colostomy
Performed in a medical emergency when closure of the colostomy is anticipated. Has TWO OPENINGS through ONE STOMA. PROXIMAL end drains STOOL and DISTAL end drains MUCUS
End Colostomy
Consists of ONE STOMA formed from the PROXIMAL END OF BOWEL w/ the dital portion of the GI tract either removed or sewn closed. For many pts, end colostomies are a result of surgical treatment of colorectal cancer.
Double-Barrel Colostomy
Bowel is surgically severed and the TWO ENDS are brought out onto the abdomen. The double-barrel colostomy consists of TWO DISTINCT STOMAS. The PROXIMAL FUNCTIONING STOMA adn the DISTAL NONFUNCTIONING STOMA (may excrete mucus)