Adult Nursing 2 Nursing assessment of the GI function

Physical Examination

Subtopic

Health history(Interview)

Chief complaint & present complain

Past medical history

Family history

Psychosocial factors

Life-style

Nutrition

Activity-Exercise

Elimination

Sleep-rest

Subtopic

Work

Coping stress

Investigation

Diagnose the problem

Urinary system

Inspection, Auscultation, Percussion and palpation

Dysphagia

Refersto difficult in swallowing and may be described as sticking, hesitating or food 'won't go down' properly

Feelings are usually associated with swallowing and can arise from disorders of the oesophagus

Ask your client

Where is the dysphagia felt

when did it start, is it intermittent or persistent

What brings it on - solid foods, softer foods? Has the dysphagia pattern changes?

Does your client have any medical conditions associated with the oesophagus?

3 broad cat. to abd. pain

Visceral pain (r/t stretching of organs)

Parietal pain (r/t inflammation, more severe than visceral pain)

Referred pain (distant pain when the original pain site is severe

After getting a history of the pain in the patient's own words, ask

patient to show where is the pain

Where does it start? Does the pain travel anywhere

How severe(bad) is the pain? Bearable? Interfere with activity?

When did it begin? How long does it lasted?

What is the pain like? ache? cramp?

When did it begin? How long it lasted?

What worsens/ relieves the pain?

Any symptoms associated with the pain? In what sequence?

Summarise

Persistent pain

Quality of pain

Radiation

Score

Time

What are the common symptoms

Analyse the presenting complaint by asking more specific questions

Characteristics, onset, severity, precipitating factors, relieving factors, associated symptoms, timing

Enquire abt the current GI status

Any changes in weight/appetite/chew/swallow/taste/pain,medications for 'stomach', dentures, oral hygiene,food allergy

Enquire abt surgeries, family history

May affect digestion, weight

Ask abt life-style,diet, work history and types of fluid intake

Health history should include information affecting the client's daily function or activities of daily living

Urine studies

Blood studies

FBC to check for WBC to determine infection

Stool studies

Stool characteristic

Color

Odour

Consistency

Radiographic studies

Barium meal OR barium enema

Endoscopic studies

OGD

Proctoscopy/ Sigmoidoscopy

Endoscopic Retrograde Cholangio-Pancreatography (ERCP)

Common complaint associated with eating

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

Excessive gas? Belching, abdominal bloating, flatus

Enquire abt food that seem to bring on these symptoms

Beans(legumes), cabbage, milk(in lactose deficient persons) are some examples

Systematic assessment can lead to prompt diagnosis and treatment

comprehensive history taking

Physical assessment

Diagnostic tests

To facilitate the diagnostic process by adequately preparing the client