NSB103 Gastrointestinal Assessment PDF

NSB103 Gastrointestinal Assessment Health Assessment School of Nursing CRICOS No.00213J Acknowledgement: Dr Helen Donovan NSB103 Health Assessment School of Nursing  ACKNOWLEDGEMENT OF TRADITIONAL OWNERS...

NSB103 Gastrointestinal Assessment Health Assessment School of Nursing CRICOS No.00213J Acknowledgement: Dr Helen Donovan NSB103 Health Assessment School of Nursing  ACKNOWLEDGEMENT OF TRADITIONAL OWNERS QUT acknowledges the Turrbal and Yugara, as the First Nations owners of the lands where QUT now stands. We pay respect to their Elders, lores, customs and creation spirits. We recognise that these lands have always been places of teaching, research and learning. QUT acknowledges the important role Aboriginal and Torres Strait Islander people play within the QUT community. CRICOS No.00213J NSB103 Health Assessment School of Nursing  Learning This Week Overview of the Gastrointestinal (GI) and Digestive System General approach to patient assessment when undertaking an abdominal assessment 4 assessment techniques to abdominal assessment The role of nutrition, hydration and elimination Some common gastrointestinal health problems Clinical Reasoning Cycle en-la-computadora-portatil-grande_1253706.htm CRICOS No.00213J NSB103 Health Assessment School of Nursing  The Digestive System Purpose: digestion of food to meet the body’s nutritional needs elimination of waste resulting from digestion CRICOS No.00213J NSB103 Health Assessment School of Nursing  Organs and Functions of the Digestive System CRICOS No.00213J NSB103 Health Assessment School of Nursing https://i.pinimg.com/originals/2f/0e/b7/2f0eb7386dbcbccd949b606679c90245.jpg CRICOS No.00213J NSB103 Health Assessment School of Nursing https://www.scribd.com/document/247061460/Anaphysio-Git  Anatomy of the Upper GI System Upper GI tract- mouth oesophagus stomach CRICOS No.00213J https://s3-us-west-2.amazonaws.com/courses-images-archive-read-only/wp- NSB103 Health Assessment content/uploads/sites/403/2015/04/21031716/2411_Pharynx.jpg School of Nursing  Upper GI System- the Mouth CRICOS No.00213J NSB103 Health Assessment http://www.passmyexams.co.uk/GCSE/biology/digestive-system.html School of Nursing  Upper GI System- Oesphagus CRICOS No.00213J https://www.heartburncanceruk.org/barretts-oesophagus NSB103 Health Assessment School of Nursing  Stomach CRICOS No.00213J NSB103 Health Assessment School of Nursing  Anatomy of the Lower GI System Lower GI tract- small intestine, large intestine, rectum, anus Solid viscera: spleen, pancreas, liver (accessory organs) CRICOS No.00213J NSB103 Health Assessment School of Nursing  Small Intestine CRICOS No.00213J NSB103 Health Assessment School of Nursing  Intestinal Lining- Small Intestine CRICOS No.00213J NSB103 Health Assessment http://www.drsusanjamieson.com/wp-content/uploads/2018/03/Gastrointestinal- School of Nursing Tract-with-closeup-of-Intestinal-Lining-including-Mucosal-Barrier.jpg  Intestinal Lining- Small and Large Bowel CRICOS No.00213J NSB103 Health Assessment School of Nursing https://i.pinimg.com/736x/08/80/b6/0880b6c98b800147fa5b6fb60c722414.jpg  Large Intestine CRICOS No.00213J NSB103 Health Assessment School of Nursing https://www.nursingtimes.net/clinical-archive/gastroenterology/gastrointestinal-tract-5-anatomy-functions-large-intestine-23-09-2019/  Accessory Organs of the Digestive System: Liver, Gallbladder, Pancreas CRICOS No.00213J https://www.webmd.com/digestive-disorders/picture-of-the-gallbladder NSB103 Health Assessment School of Nursing  Abdominal Muscles Abdominal Wall Muscles: External abdominal oblique; Internal abdominal oblique; Transverse abdominus. Function: to protect the internal organs and allowing normal functional compression activities. Eg. Coughing, sneezing, urination, defecation and childbirth. CRICOS No.00213J NSB103 Health Assessment School of Nursing  Abdominal Muscles in Pregnancy In pregnancy the rectus abdominis separates Impacts on the pregnant woman’s ability to set her core muscles CRICOS No.00213J NSB103 Health Assessment School of Nursing  Focused Gastrointestinal System Assessment Fundamentals of Nursing Clinical Skill 17.5 (2021 ed) or 24.5 (2017 ed): Focused Gastrointestinal Assessment Review baseline assessment data Perform hand hygiene Comfort/Privacy/Explain procedure Approach from right hand side of patient; position supine if possible Inspect abdomen Auscultate for presence of bowel sounds Gently percuss over abdomen Lightly palpate each quadrant Assess for recent and frequency of bowel movements Determine frequency of gastrointestinal assessment based on patient’s condition CRICOS No.00213J NSB103 Health Assessment School of Nursing  Objective Assessment of the Abdomen Inspection Auscultation Percussion Palpation Equipment required: CRICOS No.00213J https://www.amazon.com/Prestige-Medical-Clinical-Stethescope-Green/dp/B005KDAMM8 NSB103 Health Assessment School of Nursing  Abdominal Regions and Quadrants CRICOS No.00213J NSB103 Health Assessment School of Nursing https://almostadoctor.co.uk/encyclopedia/abdominal-examination Abdominal Regions and Pain- Indications CRICOS No.00213J NSB103 Health Assessment School of Nursing https://i.pinimg.com/736x/8c/01/8f/8c018f32e02530d6469d601a8b480914.jpg Assessment: Inspection Inspect: Contour Symmetry Skin: colour, moisture, scaring Pulsation or movement Umbilicus: midline, inverted, everted, swelling Stoma Laparoscopic Cholecystectomy Striae – stretch marks / https://www.ostomy.org/know-your-ostomy Caesarian section Appendicectomy CRICOS No.00213J NSB103 Health Assessment School of Nursing  Assessment: Auscultation All quadrants Systematically Compare quadrants Before percussion and palpation Listen for bowels sounds for 1-3 minute (present/ absent; diminished/hyperactive) Normal: low pitched continuous gurgles https://geekymedics.com/abdominal-examination/ CRICOS No.00213J NSB103 Health Assessment School of Nursing  Different Bowel Sounds CRICOS No.00213J https://lms.rn.com/getpdf.php/2054.pdf NSB103 Health Assessment School of Nursing  Assessment: Percussion Percuss: To determine the size of solid organs, and presence of masses, fluid and gas. All 4 quadrants Undertaken my medical staff and expert nursing staff CRICOS No.00213J NSB103 Health Assessment School of Nursing  Assessment: Palpation Assessing the shape, and size of organs. Tenderness or pain Rebound tenderness Light or deep palpation https://www.dreamstime.com/stock-photo-stomach- examination-doctor-s-hands-pressing-woman Liver and spleen palpation Muscle rigidity Stand to the right side of the patient Palpate painful areas last Patient relaxed Guarding – involuntary reflex (local rigidity) All regions systematically Watch patient’s facial expression all of the time Non tender first CRICOS No.00213J NSB103 Health Assessment School of Nursing  Focused Gastrointestinal History- Subjective Data Change in appetite Weight gain or weight loss Presence of dysphagia Intolerance to certain foods Nausea and/or vomiting Change in bowel habits Abdominal pain (Jarvis, 2011) CRICOS No.00213J https://www.dietvsdisease.org/ibs- medication/ NSB103 Health Assessment School of Nursing  Other Subjective Data Related to GI Medications Assessment Laxatives, stool softeners Iron supplements Opioids Nutritional assessment Difficulty chewing https://graphicriver.net/item/cartoon-fruits-and-vegetables-in-group/19975214 Pain in relation to eating and digestion Meal preferences Social history and lifestyle risk factors Meal preparation difficulties Financial constraints Ability to access shops etc. Sleep and rest CRICOS No.00213J Activities https://www.dietvsdisease.org/ibs-medication NSB103 Health Assessment School of Nursing  Nutritional Assessment Malnutrition Assessment of the Adult: Height Nutritional Risk: Overnutrition Weight (changes) the intake of nutrients is oversupplied and the Typical diet and recent amount of nutrients exceeds the amount required changes to diet for normal growth, development, and metabolism. Waist/girth measurement BMI Nutritional Risk: Undernutrition – Risk Factors Hospitalisation Social isolation Poverty Disability (inability to purchase and/or prepare food) Inability to feed self Malabsorption CRICOS No.00213J Poor appetite NSB103 Health Assessment School of Nursing  Waist Measurement CRICOS No.00213J NSB103 Health Assessment School of Nursing  Body Mass Index (BMI) CRICOS No.00213J NSB103 Health Assessment School of Nursing https://pilates1901.com/skinny-assessment-stats/body-mass-index/  Dietary Guidelines The average adult needs about 8700kj’s per day 1) Eat enough food from each of the 5 food groups every day 2) Choose different varieties of food from each food group 3) East: plenty of plant foods; moderate amounts of animal foods; small amounts of extra foods, margarines and oils 4) Drink plenty of water (National Health and Medical Research Council, 2013) CRICOS No.00213J https://www.eatforhealth.gov.au/sites/default/files/content/The%20Guidelines/n55_agthe_large.pdf https://www.eatforhealth.gov.au/sites/default/files/content/The%20Guidelines/final_igthe_a3_poster_-_lr.p NSB103 Health Assessment School of Nursing  Nutrition- Developmental Considerations Newborn: Suck and swallow Breastfeeding/Infant formula Frequency of feeds Volume of feeds Toddler : Teeth, move food around their mouth, chew, and swallow Typical daily meal plan: Solid foods and fluids, snacks, sugary drinks, bottles in bed (dental caries) Allergies, intolerances, medications Youth: Rapid growth = increased energy requirements CRICOS No.00213J Typical daily eating: Perceptions of their weight Understanding of balanced diet NSB103 Health Assessment School of Nursing Extreme use of diets  Indicators of Good Nutritional Status Alert, energetic Good attention span Weight within healthy range Firm well developed muscles Skin elastic, smooth Eyes bright and clear Hair shiny, minimal loss Mucous membranes pink and moist Abdomen flat and firm No skeletal changes CRICOS No.00213J http://www.celebrityhealthinsider.com NSB103 Health Assessment School of Nursing  Indicators of Poor Nutritional Status Withdrawn, fatigued Inattentive and irritable Overweight or underweight Wasted appearance, flaccid muscles Skin dull, pasty Eyes dull, pale conjunctiva Mucous membranes: red, boggy, bleed easily Abdomen flaccid or distended Skeletal changes https://www.themedicalconcierge.com. CRICOS No.00213J NSB103 Health Assessment School of Nursing  Under Nutrition and the Older adult Risk factors Oral health Loss of appetite Impacts on Reduced sensation of taste Nutrition Medication induced Socialisation Inability to chew food Positive self-concept Inability to swallow food Inability to digest food Inability to chew due Reduced saliva (dry mouth) to Loss of teeth Social implications Painful teeth and Financial; gums Situational; Sensitive teeth Physical; Receding, bleeding Psychological. gums CRICOS No.00213J Ill-fitting dentures NSB103 Health Assessment School of Nursing  Nutritional Assessment: the Mini Nutritional Assessment (MNA) Tool CRICOS No.00213J NSB103 Health Assessment School of Nursing https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0011/388235/11.-Mini-Nutritional-Assessment-MNA.pdf  Hydration Health Assessment CRICOS No.00213J NSB103 Health Assessment School of Nursing  Hydration – Health Assessment Moist skin and mucous membranes Bright clear eyes Normotensive (normal BP) Normal range heart rate Normal range body temperature Lucid and orientated Faeces soft and formed Urine – straw coloured Fluid input ~ 1500 mls per day Urine output reflects the input Stable weight CRICOS No.00213J NSB103 Health Assessment School of Nursing  Dehydration in Adults Hypotension Thirst Sunken eyes Dry mouth Cracked lips Poor skin turgor Fever Tachycardia Dry mucous membrane Tears decreased Mental disorientation confusion Weight loss Oliguria (dark amber colour) Input less than 1500 mls/day CRICOS No.00213J NSB103 Health Assessment School of Nursing https://pedialyte.com/dehydration-symptoms-causes  Dehydration in Infants Output > input Oral intake Fluid loss (vomiting and diahorrea) Check nappy contents Dehydration described as percentage of body weight dehydrated Tachycardia Dry skin & mucous membranes Sunken anterior fontanelle Circulation changes (mottling, coolness) Loss of elasticity Prolong capillary refill Oliguria CRICOS No.00213J Reduce tears Irritable NSB103 Health Assessment School of Nursing https://pedialyte.com/dehydration-symptoms-causes  Hydration Health Assessment Bounding pulse Overhydrated Hypertensive Raised Jugular Venous Pressure Drinking too much fluid Oedema Diabetes insipidus Dependent and pitting Retaining too much fluid Neurological changes Level of consciousness Kidney Confusion Cardiovascular Headache Seizures Respiratory Pulmonary congestion Polyuria Pale urine Nausea and vomiting CRICOS No.00213J Muscle spasm and weakness NSB103 Health Assessment School of Nursing  Normal faeces Faecal Elimination Soft, formed stools. Influenced by diet Newborn: meconium (black tarry) Adult: Brown to green colour Constipation Decrease in frequency passing hard dry pebbly stool Diarrhoea https://www.gezondheid.be/picts/XTRA/pasgeb-mecon-170-08.jpg Frequent bowel movements Loose to fluid motions Assessment: Changes from normal routine, size consistency and colour should be noted. CRICOS No.00213J NSB103 Health Assessment School of Nursing  The Bristol Stool Chart CRICOS No.00213J NSB103 Health Assessment School of Nursing https://www.continence.org.au/pages/bristol-stool-chart.html  Common Health Problems Related to the Upper GI System Upper GI tract (mouth, oesphagus, stomach, duodenum): Mucositis (mouth ulcers) Oesophageal varices Indigestion; gastroeosophageal reflux disease (GORD) https://www.thesun.co.uk/living/2288967/what- causes-mouth-ulcers-and-how-to-treat-them- Gastritis; gastroenteritis with-stuff-you-have-at-home/ Dysphagia Peptic ulcers Pyloric stenosis Hiatus hernia Nausea and vomiting (symptoms of other causes) CRICOS No.00213J https://www.mayoclinic.org/diseases-conditions/hiatal-hernia/symptoms-causes/syc-20373379 https://www.news-medical.net/health/Esophageal-Varices.aspx NSB103 Health Assessment School of Nursing  Common Health Problems Related to the Lower GI System Lower GI tract: Constipation Diarrhea Faecal incontinence Prolapse of the bowel Bowel cancer Celiac disease https://www.drugwatch.com/health/digestive-health/crohns-disease/ Crohn’s disease Ulcerative colitis Diverticular disease Irritable bowel syndrome Haemorrhoids Other: Dehydration/Malnutrition CRICOS No.00213J https://www.gastroconsa.com/patient-education/diverticular-disease/ https://www.shutterstock.com/search/ulcerative+colitis NSB103 Health Assessment School of Nursing  Consider the person and the context. Who is the person? Where are they living? Who supports them? What is their experience? Present, past, family history. Collect Cues and Information. Subjective and objective Data Processing the Information. Compare the data against normal parameters. Analyse, organise, categorising. Identify potential health issues/problems. Relate back to the data for relevance and direction. CRICOS No.00213J Set goals in collaboration with the person and their family NSB103 Health Assessment Each goal is aligned with each potential health issue or problem. School of Nursing  Potential Health Problems Related to the Gastrointestinal System Inadequate nutrition relating to Imbalanced nutrition related to an inability malabsorption to purchase food due to financial constraints Inadequate nutrition relating to decreased Imbalanced nutrition relating to reduction in appetite mobility Anxiety relating to faecal incontinence Social isolation due to inability to meet with Constipation relating to decreased friend for social morning tea gatherings physical activity Impaired hydration relating to nausea and Goals: realistic, timely, achievable, collaborative. vomiting For example: Reduce symptoms of nausea CRICOS No.00213J and vomiting to improve hydration levels. NSB103 Health Assessment School of Nursing  References Department of Health (2013). The Australian Guide to Healthy Eating. Retrieved from https://www.eatforhealth.gov.au/sites/default/files/content/The%20Guidelines/n55_agthe_large.pdf Calleja, P., Theobald, K., & Harvey, T. (2020). (Eds.). Health Assessment and Physical Examination. Australian and New Zealand (2nd Ed) Hockenberry, M. & Wilson, D. (2011). (Eds.). Wong’s. Nursing care of Infants and Children. (9th Ed). Elsevier. Mosby. Jarvis, C., Forbes, H., & Watt, E., (2011). (Eds.). Jarvis’s Physical Examination and Health Assessment (2nd Ed). Australia: Elsevier. Lewis, P., & Foley, D. (2011). (Eds.). Weber & Kelly’s Health Assessment in Nursing. First Australian and New Zealand Edition. Sydney AUS: Wolters Kluwer: Lippincott Williams & Wilkins. National Health and Medical Research Council (2013). Australian Dietary Guidelines. Canberra Watt, E. (2017). Maintaining urinary elimination. In Potter and Perry’s fundamentals of nursing, Elsevier, Chatswood. Wilson, S., & Giddens, J. (2012). Health Assessment for Nursing Practice. (5th Ed.). USA: Elsevier Mosby. CRICOS No.00213J NSB103 Health Assessment School of Nursing