Adult Nursing 2 Nursing assessment of the GI function
Summary
To facilitate the diagnostic process by adequately preparing the client
Systematic assessment can lead to prompt diagnosis and treatment
Diagnostic tests
Physical assessment
comprehensive history taking
Indigestion
Excessive gas? Belching, abdominal bloating, flatus
Beans(legumes), cabbage, milk(in lactose deficient persons) are some examples
Enquire abt food that seem to bring on these symptoms
It is impt to find out what your client means
heart burn, burning/ warmth sensation felt retrosternally and may radiate
Pay attention to what brings on the discomfort and what relieves it
Common complaint associated with eating
Diagnostic test
Endoscopic studies
Endoscopic Retrograde Cholangio-Pancreatography (ERCP)
Proctoscopy/ Sigmoidoscopy
OGD
Radiographic studies
Barium meal OR barium enema
Stool studies
Stool characteristic
Consistency
Odour
Color
Blood studies
FBC to check for WBC to determine infection
Urine studies
Sequence of question
Health history should include information affecting the client's daily function or activities of daily living
Ask abt life-style,diet, work history and types of fluid intake
Enquire abt surgeries, family history
May affect digestion, weight
Enquire abt the current GI status
Any changes in weight/appetite/chew/swallow/taste/pain,medications for 'stomach', dentures, oral hygiene,food allergy
Analyse the presenting complaint by asking more specific questions
Characteristics, onset, severity, precipitating factors, relieving factors, associated symptoms, timing
What are the common symptoms
Abdominal pain
Summarise
Time
Score
Radiation
Quality of pain
Persistent pain
After getting a history of the pain in the patient's own words, ask
Any symptoms associated with the pain? In what sequence?
What worsens/ relieves the pain?
When did it begin? How long it lasted?
What is the pain like? ache? cramp?
When did it begin? How long does it lasted?
How severe(bad) is the pain? Bearable? Interfere with activity?
Where does it start? Does the pain travel anywhere
patient to show where is the pain
3 broad cat. to abd. pain
Referred pain (distant pain when the original pain site is severe
Parietal pain (r/t inflammation, more severe than visceral pain)
Visceral pain (r/t stretching of organs)
Swallowing difficulty
Ask your client
Does your client have any medical conditions associated with the oesophagus?
What brings it on - solid foods, softer foods? Has the dysphagia pattern changes?
when did it start, is it intermittent or persistent
Where is the dysphagia felt
Dysphagia
Feelings are usually associated with swallowing and can arise from disorders of the oesophagus
Refersto difficult in swallowing and may be described as sticking, hesitating or food 'won't go down' properly
Inspection, Auscultation, Percussion and palpation
Urinary system
What info do I need to know more abt pt?
Diagnose the problem
Investigation
Health history(Interview)
Life-style
Coping stress
Work
Sleep-rest
Elimination
Activity-Exercise
Nutrition
Psychosocial factors
Family history
Past medical history
Chief complaint & present complain
Physical Examination
Subtopic
