NCM116 Nutrition and Metabolism Part 1 PDF

NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1) ANATOMY AND PHYSIOLOGY: AN ESOPHAGUS OVERVIEW  Located in the media...

NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1) ANATOMY AND PHYSIOLOGY: AN ESOPHAGUS OVERVIEW  Located in the mediastinum, anterior to the spine and posterior to the trachea INTRODUCTION and heart.  The gastrointestinal (GI) system, also  A hollow muscular tube, which is called the digestive system, consists of approximately 25 cm (10 inches) in the GI tract and its associated organs length, passes through the diaphragm at and glands. an opening called the diaphragmatic  Included in the GI tract are the mouth, hiatus. esophagus, stomach, small intestine, large intestine, rectum, and anus. STOMACH  The associated organs are the liver, pancreas, and gallbladder  Problems that change physiologic processes or associated organs affect a person’s ability to maintain nutrition status and eliminate waste ANATOMY OF THE GASTROINTESTINAL SYSTEM  The GI tract is a pathway 7 to 7.9 meters (23 to 26 feet) in length that extends from the mouth to the esophagus, stomach, small and large intestines, and rectum, to the terminal structure, the anus  Situated in the upper portion of the abdomen to the left of the midline, under the left diaphragm.  A distensible pouch with a capacity of approximately 1500 mL.  The inlet is called the esophagogastric junction; it is surrounded by a ring of smooth muscle called the lower esophageal sphincter (or cardiac sphincter), which, on contraction, closes off the stomach from the esophagus.  The stomach can be divided into four anatomic regions:  cardia (entrance)  fundus NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1)  body  located in the right lower portion  pylorus (outlet). of the abdomen.  Circular smooth muscle in the wall of the  Ileocecal valve is located at this pylorus forms the pyloric sphincter and junction. controls the opening between the  It controls the passage of stomach and the small intestine. intestinal contents into the large intestine and prevents reflux of SMALL INTESTINE bacteria into the small intestine.  The vermiform appendix is located near this junction LARGE INTESTINE  The longest segment of the GI tract,  Consists of: accounting for about two thirds of the  ascending segment - on the total length. right side of the abdomen  It folds back and forth on itself, providing  transverse segment - extends approximately 7000 cm of surface area from right to left in the upper for secretion and absorption, the abdomen, process by which nutrients enter the  descending segment - on the bloodstream through the intestinal walls. left side of the abdomen.  Divided into three anatomic parts:  The terminal portion of the large intestine  upper part - duodenum consists of two parts:  middle part- jejunum  sigmoid colon  lower part- ileum  rectum  Common bile duct allows for the  The rectum is continuous with the anus. passage of both bile and pancreatic  A network of striated muscle that forms secretions both the internal and the external anal  empties into the duodenum at sphincters regulates the anal outlet. the ampulla of Vater.  Cecum is the junction between the small BLOOD SUPPLY and large intestine NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1)  The GI tract receives blood from arteries that originate along the entire length of the thoracic and abdominal aorta.  Of particular importance are the gastric artery and the superior and inferior mesenteric arteries.  Oxygen and nutrients are supplied to the stomach by the gastric artery and to the intestine by the mesenteric).  The GI tract has its own nervous system:  Blood is drained from these organs by the enteric nervous system (ENS) or veins that merge with others in the intrinsic nervous system. abdomen to form a large vessel called  The ENS system regulates motility and the portal vein. secretion along the entire GI tract.  Nutrient-rich blood is then carried to the  The ENS is composed of 2 networks: liver. 1) Meissner plexus in the submucosa  The GI tract and accessory organs 2) Auerbach (myenteric) plexus receive 25% to 30% of the cardiac output between the muscle layers. at rest and 35% or more after eating.  The submucosal plexus controls  Because such a large percent of the secretion and is involved in many cardiac output perfuses these organs, sensory functions. the GI tract is a major source from which  The myenteric plexus is the major nerve to divert blood flow during exercise, supply to the GI tract and controls GI stress, or injury movements.  Although the ENS receives innervation INNERVATION from the ANS, it functions independently of the brain and spinal  Both the sympathetic and cord. parasympathetic portions of the autonomic nervous system innervate the FUNCTION OF THE DIGESTIVE SYSTEM GI tract.  Parasympathetic and sympathetic Major functions of the GI tract include: branches of the autonomic nervous  Breakdown of food particles into the system (ANS) innervate the GI tract. molecular form for digestion  Parasympathetic (cholinergic)  Absorption into the bloodstream of system is mainly excitatory. small nutrient molecules produced by  Sympathetic (adrenergic) digestion system is mainly inhibitory  Elimination of undigested unabsorbed  The only portions of the tract that are foodstuffs and other waste products under voluntary control are the upper esophagus and the external anal TERMS sphincter.  Digestion: phase of the digestive process that occurs when enzymes mix NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1) with ingested food and when proteins, fats, and sugars are broken down into their component molecules  Absorption: phase of the digestive process that occurs when small molecules, vitamins, and minerals pass through the walls of the small and large intestine and into the bloodstream  Elimination: phase of the digestive process that occurs after digestion and absorption, when waste products are eliminated from the body CHEWING  The process of digestion begins with the act of chewing, in which food is broken down into small particles that can be swallowed and mixed with digestive enzymes.  Eating—or even the sight, smell, or taste of food—can cause reflex salivation.  Approximately 1.5 L of saliva is secreted daily from the parotid, the submaxillary, and the sublingual glands.  Ptyalin, or salivary amylase, is an enzyme that begins the digestion of starches.  Water and mucus, also contained in saliva, help lubricate the food as it is MAJOR DIGESTIVE ENZYMES AND chewed, thereby facilitating swallowing. SECRETIONS  Mouth: saliva, salivary amylase  Stomach: hydrochloric acid, pepsin, intrinsic factor  Small intestine: amylase, lipase, trypsin, bile NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1) GASTRIC FUNCTIONS SWALLOWING  The stomach, which stores and mixes  Swallowing begins as a voluntary act food with secretions, secretes a highly that is regulated by the swallowing center acidic fluid in response to the presence in the medulla oblongata of the central or anticipated ingestion of food. nervous system (CNS).  This fluid, which can total 2.4  As a bolus of food is swallowed, the L/day, can have a pH as low as epiglottis moves to cover the tracheal 1 and derives its acidity from opening and prevent aspiration of food hydrochloric acid (HCl) into the lungs. secreted by the glands of the  Swallowing, which propels the bolus of stomach. food into the upper esophagus, thus ends  The function of this gastric secretion is as a reflex action twofold:  The smooth muscle in the wall of the  to break down food into more esophagus contracts in a rhythmic absorbable components sequence from the upper esophagus  to aid in the destruction of most toward the stomach to propel the bolus of ingested bacteria. food along the tract.  Pepsin, an important enzyme for protein  During this process of esophageal digestion, is the end product of the peristalsis, the lower esophageal conversion of pepsinogen from the chief sphincter relaxes and permits the bolus cells. of food to enter the stomach.  Intrinsic factor is also secreted by the  Subsequently, the lower esophageal gastric mucosa, combines with dietary sphincter closes tightly to prevent reflux vitamin B12 so that the vitamin can be of stomach contents into the esophagus. absorbed in the ileum.  In the absence of intrinsic factor, vitamin B12 cannot be absorbed, and pernicious anemia results  Peristaltic contractions in the stomach propel the stomach’s contents toward the pylorus. Because large food particles cannot pass through the pyloric sphincter, they are churned back into the body of the stomach. In this way, food in the stomach is mechanically broken down into smaller particles.  Food remains in the stomach for a variable length of time, from 30 minutes to several hours, depending on the volume, osmotic pressure, and chemical composition of the gastric contents.  Peristalsis in the stomach and contractions of the pyloric sphincter allow NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1) the partially digested food to enter the secretions control the rate of intestinal small intestine at a rate that permits secretions and also influence GI motility. efficient absorption of nutrients. This  Intestinal secretions total approximately partially digested food mixed with gastric 1 L/day of pancreatic juice, 0.5 L/day of secretions is called chyme. bile, and 3 L/day of secretions from the  Hormones, neuroregulators, and local glands of the small intestine. regulators found in the gastric secretions  Two types of contractions occur regularly control the rate of gastric secretions and in the small intestine: segmentation influence gastric motility contractions and intestinal peristalsis.  Segmentation contractions SMALL INTESTINE FUNCTIONS produce mixing waves that move the intestinal contents back and  The digestive process continues in the forth in a churning motion. duodenum.  Intestinal peristalsis propels  Duodenal secretions come from the the contents of the small accessory digestive organs—the intestine toward the colon. Both pancreas, liver, and gallbladder—and movements are stimulated by the glands in the wall of the intestine the presence of chyme. itself. These secretions contain digestive  Food, ingested as fats, proteins, and enzymes: amylase, lipase, and bile. carbohydrates, is broken down into  Pancreatic secretions have an alkaline absorbable particles (constituent pH due to their high concentration of nutrients) by the process of digestion. bicarbonate.  Carbohydrates are broken down into  This alkalinity neutralizes the disaccharides (e.g., sucrose, maltose, acid entering the duodenum from galactose) and monosaccharides (e.g., the stomach. glucose, fructose).  Digestive enzymes secreted by the  Glucose is the major pancreas include trypsin, which aids in carbohydrate that tissue cells digesting protein; amylase, which aids in use as fuel. digesting starch; and lipase, which aids  Proteins are a source of energy after in digesting fats. they are broken down into amino acids  These secretions drain into the and peptides. pancreatic duct, which empties  Ingested fats become monoglycerides into the common bile duct at the and fatty acid through emulsification, ampulla of Vater. which makes them smaller and easier to  Bile, secreted by the liver and stored in absorb. the gallbladder, aids in emulsifying  Chyme stays in the small intestine for 3 ingested fats, making them easier to to 6 hours, allowing for continued digest and absorb. breakdown and absorption of nutrients.  Sphincter of Oddi, found at the  Small, fingerlike projections called villi confluence of the common bile duct and line the entire intestine and function to duodenum, controls the flow of bile. produce digestive enzymes as well as to  Hormones, neuroregulators, and local absorb nutrients. regulators found in these intestinal NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1)  Absorption is the major function of  Mucus protects the colonic the small intestine. mucosa from the intraluminal  Vitamins and minerals are absorbed contents and provides essentially unchanged. adherence for the fecal mass.  Absorption begins in the jejunum and  Slow, weak peristalsis moves the colonic is accomplished by active transport and contents along the tract. This slow diffusion across the intestinal wall into the transport allows for efficient reabsorption circulation. of water and electrolytes, which is the  Nutrients are absorbed at specific major function of the colon. locations in the small intestine and  Intermittent strong peristaltic waves duodenum. propel the contents for considerable  Fats, proteins, carbohydrates, sodium, distances. and chloride are absorbed in the jejunum.  This generally occurs after another meal  Vitamin B12 and bile salts are absorbed is eaten, when intestine-stimulating in the ileum. hormones are released.  Magnesium, phosphate, and potassium  The waste materials from a meal are absorbed throughout the small eventually reach and distend the rectum, intestine. usually in about 12 hours.  As much as one fourth of the waste COLONIC FUNCTIONS materials from a meal may still be in the rectum 3 days after the meal was  Within 4 hours after eating, residual ingested. waste material passes into the terminal ileum and slowly into the proximal portion WASTE PRODUCTS OF DIGESTION of the right colon through the ileocecal valve.  Feces consist of undigested foodstuffs,  With each peristaltic wave of the small inorganic materials, water, and bacteria. intestine, the valve opens briefly and  Fecal matter is about 75% fluid and 25% permits some of the contents to pass into solid material. The composition is the colon. relatively unaffected by alterations in diet  Gut microbes (bacteria), a major because a large portion of the fecal mass component of the contents of the large is of nondietary origin, derived from the intestine, assist in completing the secretions of the GI tract. breakdown of waste material, especially  The brown color of the feces results of undigested or unabsorbed proteins from the breakdown of bile by the and bile salts. intestinal bacteria.  Two types of colonic secretions are  Chemicals formed by intestinal bacteria added to the residual material: an are responsible in large part for the fecal electrolyte solution and mucus. odor.  Electrolyte solution is chiefly a  Gases formed contain methane, bicarbonate solution that acts to hydrogen sulfide, and ammonia, neutralize the end products among others. formed by the colonic bacterial  The GI tract normally contains action approximately 150 mL of these NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1) gases, which are either against invading pathogens, regulatory absorbed into the portal influences on innate and adaptive circulation and detoxified by the immune responses, and inflammation. liver or expelled from the rectum  Colonization of the GI tract begins shortly as flatus. after birth; the normal gut microbiota is  Elimination of stool begins with distention established by 2 years of age. of the rectum, which initiates reflex  Several factors over time affect the contractions of the rectal musculature composition of normal gut microbiota and relaxes the normally closed internal including genetics, diet, personal anal sphincter. hygiene, infection, and vaccinations.  The internal sphincter is controlled by the  The number and diversity of microbes autonomic nervous system; the external within the gut change with aging and are sphincter is under the conscious control influenced by diet, chronic disease, and of the cerebral cortex. medications. Additionally, administration  During defecation, the external anal of broad-spectrum antibiotics can disrupt sphincter voluntarily relaxes to allow the gut microbiota and lead to overgrowth colonic contents to be expelled. of potentially pathogenic species Normally, the external anal sphincter is  The gut microbiome, the collective maintained in a state of tonic contraction. genome of the microbiota, protects the  Defecation is seen to be a spinal reflex host against invasion by pathogenic (involving the parasympathetic nerve organisms; it produces anti-inflammatory fibers) that can be inhibited voluntarily by metabolites, destroys toxins, prevents keeping the external anal sphincter colonization of pathogens, and provokes closed. an immune response  Contracting the abdominal muscles  The intestinal epithelium is the first line (straining) facilitates emptying of the of defense against pathogenic microbes colon. and microbial agents, as it contains  The average frequency of defecation in innate immune cells such as humans is once daily, but this varies macrophages, dendritic cells, among people. granulocytes, and mast cells, and has a role in T-cell responses GUT MICROBIOME  Peyer’s patches (gut-associated lymph tissue) also have a role in antigen  In addition to assisting in the breakdown processing and immune defense. of waste material, the gut microbiota the  Collectively, the gut microbiome serves complement of microbes in the GI tract) the roles of protection and defense. also has a role in vitamin synthesis and immune function, including protection NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1)  Abdominal pain, dyspepsia, gas, ASSESSMENT OF THE GASTROINTESTINAL nausea and vomiting, SYSTEM constipation, diarrhea, fecal HEALTH HISTORY continence, change in bowel patterns, characteristics of stool,  Include all information related to GI jaundice, history of GI surgery or function problems, appetite and eating patterns, teeth, and nutritional NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1) assessment, including weight  Assess knowledge; need for patient patterns education  Psychosocial, spiritual, and cultural factors  Defecation pattern PAIN  a major symptom of GI disease COMMON SITES OF REFERRED  abdominal pain is a common ABDOMINAL PAIN presentation in the ambulatory setting  Assessment:  Character  Duration  Pattern  Frequency  Location  Distribution of referred pain  Time of the pain  Factors:  Meals  Rest DYSPEPSIA  Activity NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1)  upper abdominal discomfort associated  CNS disorders with eating (commonly called  irritation of the chemoreceptor indigestion)—is the most common trigger zone from radiation symptom of patients with GI dysfunction. therapy, systemic disorders, and  Indigestion is an imprecise term that endogenous and exogenous refers to a host of upper abdominal or toxins, which may include epigastric symptoms such as pain, specific classes of drugs discomfort, fullness, bloating, early  Distention of the duodenum or upper satiety, belching, heartburn, or intestinal tract is a common cause of regurgitation nausea; it may also be an early warning  Causes: sign of a pathologic process.  Fatty foods  Salads CHANGE IN BOWEL HABITS AND STOOL  Coarse vegetables CHARACTERISTICS  Highly seasoned foods  Changes in bowel habits may signal INTESTINAL GAS colonic dysfunction or disease.  Diarrhea, an abnormal increase in the  The accumulation of gas in the GI tract frequency and liquidity of the stool or in may result in belching (expulsion of gas daily stool weight or volume, commonly from the stomach through the mouth) or occurs when the contents move so flatulence (expulsion of gas from the rapidly through the intestine and colon rectum). that there is inadequate time for the GI  Usually, gases in the small intestine pass secretions and oral contents to be into the colon and are released as flatus. absorbed.  Patients often complain of bloating,  Typically associated with distention, or feeling “full of gas” with abdominal pain or cramping and excessive flatulence as a symptom of nausea or vomiting. food intolerance or gallbladder disease  Constipation—a decrease in the frequency of stool, or stools that are hard, NAUSEA AND VOMITING dry, and of smaller volume than typical— may be associated with anal discomfort  Nausea is a vague, uncomfortable and rectal bleeding, and is a frequent sensation of sickness or “queasiness” reason patients seek health care that may or may not be followed by referrals vomiting. It can be triggered by odors,  The characteristics of the stool can vary activity, medications, or food intake. greatly.  Vomiting is a physiologic protective  Stool is normally light to dark response that limits the effects of noxious brown; however, specific agents by emptying the stomach disease processes and ingestion contents and sections of the small of certain foods and medications intestine may change the appearance of  Causes: stool.  visceral afferent stimulation NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1)  Blood in the stool can present in various  Recent history of sore throat or bloody ways and must be investigated. sputum  If blood is shed in sufficient  Discomfort caused by certain foods; daily quantities into the upper GI food intake tract, it produces a tarry-black  Use of alcohol and tobacco, including color (melena), whereas blood smokeless chewing tobacco entering the lower portion of  Past and current medication use, and the GI tract or passing rapidly any previous diagnostic studies, through it will appear bright or treatments, or surgery are noted. dark red.  Current nutritional status is assessed via  Lower rectal or anal bleeding history; laboratory tests (complete is suspected if there is streaking metabolic panel including liver function of blood on the surface of the studies, triglyceride, iron studies, and stool or if blood is noted on toilet complete blood count [CBC]) are tissue. obtained.  Other common abnormalities in stool  History of the use of tobacco and alcohol characteristics described by the patient includes details about type, amount, may include: length of use, and the date of  Bulky, greasy, foamy stools discontinuation, if any. that are foul in odor and may or  Changes in appetite or eating patterns may not float and any unexplained weight gain or loss  Light gray or clay-colored over the past year. stool, caused by a decrease or  Psychosocial, spiritual, or cultural absence of conjugated bilirubin factors.  Stool with mucus threads or pus that may be visible on gross MEDICATIONS inspection of the stool  Assess the patient’s past and current use  Small, dry, rock-hard masses of medications. Include information about occasionally streaked with blood probiotics and nutrition supplements.  Loose, watery stool that may or  Many medications cause side effects in may not be streaked with blood the GI system.  GI problems can affect drug absorption and effectiveness.  Antacids and laxatives may affect medication absorption.  Many chemicals, herbal supplements, and drugs may be hepatotoxic.  Examples include chronic high doses of acetaminophen and nonsteroidal anti- PAST HEALTH, FAMILY, AND SOCIAL inflammatory drugs (NSAIDs). HISTORY NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1)  NSAIDs may also cause upper GI  The lips should be moist, pink, smooth, bleeding, with an increasing risk as the and symmetric. person ages.  The patient is instructed to open the  Antibiotics, may change the normal mouth wide; a tongue blade is then bacterial composition in the GI tract, inserted to expose the buccal mucosa for resulting in diarrhea. an assessment of color and lesions. SURGERY OR OTHER TREATMENTS GUMS:  The gums are inspected for inflammation, bleeding, retraction, and discoloration.  The odor of the breath is also noted.  The hard palate is examined for color and shape.  Stensen duct of each parotid gland is visible as a small red dot in the buccal mucosa next to the upper molars. TONGUE  The dorsum (back) of the tongue is inspected for texture, color, and lesions.  A thin, white coat and large, vallate papillae in a “V” formation on the distal portion of the dorsum of the tongue are normal findings.  Hospitalizations for any problems related  The patient is instructed to protrude the to the GI system. tongue and move it laterally.  Record any abdominal or rectal surgery,  This provides the examiner with including the year, reason for surgery, an opportunity to estimate the postoperative course, and blood tongue’s size as well as its transfusions. symmetry and strength (to assess the integrity of the 12 th PHYSICAL ASSESSMENT cranial nerve [hypoglossal nerve]). ORAL CAVITY  Further inspection of the ventral surface  Method: INSPECTION AND of the tongue and the floor of the mouth PALPATION is accomplished by asking the patient to  Dentures should be removed touch the roof of the mouth with the tip of the tongue. LIPS:  Any lesions of the mucosa or any  Inspection of the lips for moisture, abnormalities involving the frenulum or hydration, color, texture, symmetry, and superficial veins on the undersurface of the presence of ulcerations or fissures. NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1) the tongue are assessed for location,  Lesions are of particular importance, size, color, and pain. because GI diseases often produce skin  This is a common area for oral changes. cancer, which presents as a  The contour and symmetry of the white or red plaque, lesions, abdomen are noted, and any localized ulcers, or nodules. bulging, distention, or peristaltic waves  A tongue blade is used to depress the are identified. tongue for adequate visualization of the  Expected contours of the anterior pharynx. abdominal wall can be described as flat,  It is pressed firmly beyond the rounded, or scaphoid midpoint of the tongue; proper placement avoids a gagging AUSCULTATION response.  Auscultation always precedes  The patient is told to tip the head percussion and palpation, because they back, open the mouth wide, take may alter sounds. a deep breath, and say “ah.”  Auscultation is used to determine the  Often, this flattens the posterior character, location, and frequency of tongue and briefly allows a full bowel sounds and to identify vascular view of the tonsils, uvula, and sounds. posterior pharynx.  Bowel sounds are assessed using the  These structures are inspected diaphragm of the stethoscope for soft for color, symmetry, and clicks and gurgling sounds evidence of exudate, ulceration,  The frequency and character of the or enlargement. sounds are usually heard as clicks and  Normally, the uvula and soft palate rise gurgles that occur irregularly and range symmetrically with a deep inspiration from 5 to 30 per minute. upon saying “ah”; this indicates an intact  normal (sounds heard about vagus nerve (10th cranial nerve). every 5 to 20 seconds)  hypoactive (one or two sounds ABDOMINAL EXAMINATION in 2 minutes),  hyperactive (5 to 6 sounds INSPECTION heard in less than 30 seconds),  Ask patient to lie supine and knee flexed  absent (no sounds in 3 to 5  Four quadrant method involves the use minutes of an imaginary line drawn vertically from  Using the bell of the stethoscope, any the sternum to the pubis through the bruits in the aortic, renal, iliac, and umbilicus and a horizontal line drawn femoral arteries are noted. across the abdomen through the  Friction rubs are high pitched and can umbilicus. be heard over the liver and spleen during  Inspection is performed first, noting skin respiration. changes, nodules, lesions, scarring,  Borborygmi (“stomach growling”) is discolorations, inflammation, bruising, or heard as a loud prolonged gurgle. striae. NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1) PERCUSSION  Palpation is important because it may  Percussion is used to assess the size reveal a tumor. and density of the abdominal organs and  Begin with light palpation. Palpate any to detect the presence of air-filled, fluid- areas in which the patient reports filled, or solid masses. tenderness last.  Percussion is used either independently  Use light palpation to detect or concurrently with palpation because it tenderness or cutaneous can validate palpation findings. hypersensitivity, muscular resistance,  All quadrants are percussed for overall masses, and swelling. tympani and dullness.  Help the patient relax for deeper  Tympani is the sound that results from palpation. Keep your fingers the presence of air in the stomach and together and press gently with small intestines the pads of the fingertips,  Dullness is heard over organs and solid depressing the abdominal wall masses. about 0.4 in (1 cm). Use smooth  The use of light palpation is appropriate movements and palpate all for identifying areas of tenderness or quadrants muscular resistance, and deep palpation  Use deep palpation to delineate is used to identify masses. abdominal organs and masses  Testing for rebound tenderness is not  Use the palmar surfaces of your performed by many examiners because fingers to press more deeply. it can cause severe pain; light percussion Again, palpate all quadrants. is used instead to produce a mild  Note the location, size, and localized response when peritoneal shape of masses, as well as the irritation is present. presence of tenderness.  During these maneuvers, observe the patient’s facial expression because it will provide nonverbal cues of discomfort or pain PALPATION  Use palpation to assess the abdominal organs and detect any tenderness, distention, masses, or fluid. NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1) QUADRANTS OF THE ABDOMEN NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1) RECTAL INSPECTION AND PALPATION  Tenderness, inflammation, or  Gloves, water-soluble lubrication, a both should alert the examiner to penlight, and drapes are necessary tools the possibility of a pilonidal cyst, for the evaluation. perianal abscess, or anorectal  For women, the rectal examination may fistula or fissure. be part of the gynecologic examination.  The patient’s buttocks are carefully  Positions for the rectal examination spread and visually inspected until the include knee-chest, left lateral with patient has relaxed the external sphincter hips and knees flexed, or standing control. with hips flexed and upper body  The patient is asked to bear down, thus supported by the examination table. allowing the ready appearance of  Most patients are comfortable on the fistulas, fissures, rectal prolapse, polyps, right side with knees brought up to the and internal hemorrhoids. chest.  Internal examination is performed with  External examination includes a gloved lubricated index finger inserted inspection for lumps, rashes, into the anal canal while the patient bears inflammation, excoriation, tears, scars, down. The tone of the sphincter is noted, pilonidal dimpling, and tufts of hair at the as are any nodules or irregularities of the pilonidal area. anal ring. NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1) NCM116 - CARE OF CLIENTS WITH PROBLEMS IN NUTRITION, AND GASTROINTESTINAL, METABOLISM AND ENDOCRINE, PERCEPTION AND COORDINATION, ACUTE AND CHRONIC (PART 1)