Patient History
- Demographic Data: age, gender, culture, occupation
- Family History and Genetic Risk
- Medical History: Previous GI Disorders, Abdominal Surgeries, and Medications - Aspirin and NSAIDs may cause PUD and GI Bleeding. - Laxatives and Enemas may cause dependence, leading to constipation.
- Travel History
- Dietary History
- Socioeconomic Status
- Current Health Problem: a common complaint is pain.
- PQRST Guide Questions
- Precipitating or Palliative: what causes or relieves the presenting symptoms?
- Quality or Quantity: How severe are the symptoms? How does it look, feel, or sound?
- Region or Radiation: where is pain found? Does the pain spread or radiate anywhere?
- Severity Scale: how bad is the pain on a scale from 1 to 10?
- Timing: when was the onset, what is the duration, and how often does pain occur?
- GI Health Habits: toothbrushing, flossing, and dental visit frequency; awareness of lesions or irritated areas in the mouth, tongue, or throat; recent history of sore throat, bloody sputum, discomfort from certain foods, daily food intake, alcohol and tobacco use (including smokeless chewing tobacco, take note of type, amount, length of use, and if applicable, date of discontinuation), denture or partial plate use, medical history, previous diagnostic studies, treatments, surgeries, current nutritional status (via history, laboratory tests; complete metabolic panel including liver function studies, triglyceride, iron studies, and CBC), changes in appetite or eating patterns, unexplained weight gain or weight loss over the past year, and other questions about psychosocial, spiritual, or cultural factors that may be affecting the patient.
Health History
Obtain data on the most common symptoms of gastrointestinal disorders: abdominal pain, dyspepia (indigestion), gas, nausea and vomiting, diarrhea or constipation, fecal incontinence, jaundice, and other previous GI diseases (Weber & Kelley, 2018).
- Pain may be a major and frequent symptom of GI disease. This pain may be affected by meals, rest, activity, and defecation patterns. Character, duration, pattern, frequency, location, time, and distribution of referred pain can vary depending on the underlying cause.
- Dyspepia, commonly called “indigestion”, is the most common symptom of GI dysfunction (partly due to its broad definition). It may refer to pain, discomfort, fullness, bloating, early satiety, belching, heartburn, or regurgitation.
- 25% of Americans experience dyspepia annually.
- 20% of Americans experience GERD, increasing with age and sometimes with dyspepia.
- Typically, fats cause the most dyspepia due to their slow gastric emptying.
- Intestinal Gas may result in belching or flatulence. Patients often complain of bloating, distention, or feeling “full of gas” with excessive flatulence as a symptom of food intolerance or gallbladder disease.
- Nausea is a vague, uncomfortable sensation of sickness or “queasiness” that might be followed by vomiting, and may be an early sign of a pathologic process. It may be triggered by odors, activity, medications, or food intake.
- Often caused by distention of the upper intestinal tract or duodenum.
- Vomiting is the forceful emptying of the stomach and intestinal contents through the mouth. The emesis or vomitus may vary in color and content. It may contain undigested food, blood (hematemesis), bilous gastric juices, etc.
- Acute, bright-red/coffee-ground vomiting is characteristic of a Mallory-Weiss Tear e.g. a laceration in the mucosal lining of the gastroesophageal junction, and indicates upper GI bleeding.
- Causes for nausea and vomiting (N&V) are many. These may include: visceral pain; motion or motion sickness; anxiety; several types of intestinal, vagal, or sympathetic input (including side effects of medications); and torsion or trauma of the ovaries, testes, uterus, bladder or kidney.
- Initiation of vomiting includes pathways through medication therapy, metabolic abnormalities (chemoreceptor trigger zone), ingested toxins, chemotherapy, radiation therapy (vagal and splanchnic receptors), inner ear disorders, motion sickness (vestibular center), and anticipatory emesis (cerebral cortex).
- Bowel Habit Changes may signal colonic dysfunction or disease.
- Diarrhea is the abnormal increase in the frequency and liquidity of stool or daily stool weight or volume.
- Commonly occurs when waste products move rapidly through the intestine, resulting in inadequate forming and absorption of water content.
- Typically associated with abdominal pain, cramping, and N&V.
- Constipation is the abnormal decrease in the frequency of defecation, hardness, dryness, and/or being smaller in volume of stool than normal.
- Typically associated with anal discomfort and rectal bleeding, commonly the reason individuals seek health care referrals.
- Diarrhea is the abnormal increase in the frequency and liquidity of stool or daily stool weight or volume.
- Stool Characteristics may also signal colonic dysfunction or disease.
- Color is normally light to dark brown. Specific diseases and certain foods or medications may change color.
- Green: leafy green vegetables, spinach, and kale
- Red: beets, red gelatin, tomato soup, food coloring. Bright-red indicates lower gastrointestinal bleeding, and dark-red may indicate upper gastrointestinal bleeding.
- Black: bismuth, iron, black licorice; upper GI bleeding (tarry-black).
- Light Gray/Clay-colored: decrease of conjugated bilirubin
- Milky White: from barium, typically from barium enemas or intake for imaging
- Bulky, greasy, foamy stools that are foul in odor and may or may not float
- Stool with mucus threads or pus that may be visible upon gross inspection
- Small, dry, rock-hard masses occasionally streaked with blood
- Loose, watery stools that may or may not be streaked with blood
- Color is normally light to dark brown. Specific diseases and certain foods or medications may change color.
Physical Assessment
Also assess client nutritional Status and anthropomorphic measurement
- Oral Cavity Inspection and Palpation
| Site | Assessment | Finding |
|---|---|---|
| Lips | Inspection: moisture, hydration, color, texture, symmetry, ulcerations/fissures | Moist, pink, smooth, and symmetric |
| Gums | Inspection: inflammation, bleeding, retraction, discoloration | - |
| Breath | Odor | - |
| Oral Cavity | Inspection (Tongue Blade): color and lesions | - |
| Stensen Duct (Parotid Gland) | Inspection: visibility, color | Small red dot in the buccal mucosa next to upper molars |
| Tongue | Protrude the tongue and move it laterally | Size, symmetry and strength; integrity of the hypoglossal nerve |
| Dorsal Tongue | Inspection: texture, color, lesions | Thin white coat, large, vallate papillae in a V formation on the distal portion of the dorsum of the tongue |
| Ventral tongue | Touch the roof of the mouth with the tip of the tongue | No lesions or abnormalities |
| Ventral tongue | - | Common site for oral cancer. Assess location, size, color, and pain of lesions. |
| Pharynx (Tonsils, uvula, posterior pharynx) | Visualization: depress tongue with tongue blade | Color, Symmetry, Evidence of Exudate, Ulceration, Enlargement |
| Hard Palate | Color and shape | - |
| Uvula and Soft Palate | Inspection: open mouth, deep breath, and say “ah” | Rises symmetrically; integrity of the vagus nerve |
- Abdominal Assessment: lie the patient supine with knees flexed slightly for inspection, auscultation, percussion, and palpation of the abdomen. For documentation, the abdomen may be divided into four or nine regions.
- Inspection: Note changes of the skin, nodules, lesions (important), scarring, discoloration, inflammation, bruising, or striae, contour (flat, rounded, scaphoid), symmetry, bulging, distention, peristaltic waves.
- Auscultation: done prior to percussion and palpation as those may alter sounds. Determine character, location, and frequency of bowel sounds. Also identify vascular sounds.
- Use the diaphragm of the stethoscope to identify clicks and gurgles (usual bowel sounds). These occur irregularly and range from 5 to 30 sounds per minute. Listen for at least 5 minutes, with at least one minute in each quadrant to confirm the absence of bowel sounds.
- Use the bell of the stethoscope to identify bruits in the aortic, renal, iliac, and femoral arteries. Friction rubs are notes over the liver and spleen during respiration. Borborygmus is a long gurgle (“stomach growling”).
- Normal, Hyperactive, or Hypoactive
- Percussion: assess the size and density of the abdominal organs; detect air-filled, fluid-filled, or solid masses. It may be done independently or concurrently with palpation as it may validate palpation findings. Percuss all quadrants for tympani (high pitched) or dullness.
- Tympanic sounds are head over air-filled organs (stomach and small intestines).
- Dullness is heard over organs and solid masses.
- Deep palpation should be used for masses, and light palpation is appropriate for areas of tenderness and muscle resistance. Most examiners do not examine for rebound tenderness due to discomfort inflicted.
- Rectal Inspection and Palpation: evaluation of the terminal portions of the GI tract, the rectum, the perianal region, and anus. The anal canal is approximately 2.4 to 4 cm in length and opens to the perineum. Concentric rings of muscle, the internal and external sphincters, normally keep the anal canal securely closed. Gloves, water-soluble lubrication, a penlight, and drapes are necessary for the evaluation. This is a mandatory part of every thorough examination. For women, this may be part of a gynecologic examination. Encourage the patient to visualize pleasant scenery and focus on deep breathing.
- Positioning may include knee-chest, left lateral with hips and knees flexed, or standing with hips flexed and upper body supported by the examination table.
- External: lumps, rashes, inflammation, excoriation, tears, scars, pilonidal dimpling, and tufts of hair at the pilonidal area (above the anus, near the tailbone). The discovery of tenderness, inflammation, or both should alert the examiner to the possibility of a pilonidal cyst (cyst containing hair and pus), perianal abscess, or an anorectal fistula or fissure.
- Internal: the patient’s buttocks are carefully spread until the patient has relaxed the external sphincter control. Ask the patient to bear down, and inspect for fistulas, fissures, rectal prolapse, polyps, and internal hemorrhoids. Insert a gloved, lubricated index finger and ask the patient to bear down. The tone of the sphincter and any nodules or irregularities of the anal ring is noted.
Abdominal Assessment
- Have the client void, lie supine with knees bent, and keep the arms at the side. This should relax the abdominal muscles.
- IAPePa (as opposed to the usual IPaPeA): Inspection, Percussion, Palpation, Auscultation - Leave the reported areas with pain as the last areas to check, as pain causes involuntary abdominal tension, impeding on the assessment. - Observe for signs of pain: grimacing - Starting from the RUQ, clockwise around each quadrant
- Cullen’s Sign: ecchymosis (bruising) around the umbilicus is indicative of intra-abdominal bleeding.
- Abdominal movements indicate intestinal obstruction (hyperperistalsis). These are rarely seen upon inspection.
Auscultation
- High-pitched Gurgles: movement of air and fluid; q5-15s; 5-30 sounds/min.
- Hyperactive: 30 sounds in 1 minute.
- Hypoactive: 1-2 sounds in 2 minutes. Diminished or absent gurgling may be observed after abdominal surgery, with peritonitis, or a paralytic ileus.
- Absent: no sounds in 3 to 5 minutes.
- Borborygmus: loud gurgling sounds due to hypermotility of the bowel e.g. in gastroenteritis, diarrhea, or complete intestinal obstruction.
- Bruit: “swooshing sounds” that indicate an aneurysm (AAA), especially if heard over the abdominal aorta. Avoid percussion or palpation if observed; rupturing the aneurysm is life-threatening.
Percussion
This method is used to determine and estimate the size of solid organs such as the liver and the spleen, the presence of masses, of fluids, and of air.
- Tympanic: high-pitched, loud musical sound of an air-filled space.
- Dull: medium-pitched, softer, thud-like sound over a solid organ.
Palpation
This method (light and deep) is used to determine the size and location of abdominal organs and assess the presence of masses or tenderness (pain).
- Blumberg’s Sign: rebound tenderness; pain felt when pressure from fingers pressing perpendicular to the abdomen is removed. Found in appendicitis.