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HEALTH ASSESSMENT
Lecture 7
Denver School of Nursing
Fall 2013
K.Hendrickson PhD, RN
CHAPTER 13
Abdomen and
Gastrointestinal System
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A&P: Abdominal Cavity
•
•
•
•
•
•
Stomach
Small and large intestines
Liver
Gallbladder
Pancreas
Spleen
•
•
•
•
•
Kidneys
Ureters
Bladder
Adrenal glands
Major vessels
• Women: Uterus, fallopian tubes, ovaries
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Anatomy and Physiology
• Esophagus lies outside abdominal cavity but is vital part
of gastrointestinal (GI) system.
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A&P: Peritoneum, Musculature, & Connective Tissue
• Peritoneum: serous
membrane
forming a protective cover.
• Divided into two layers:
• Parietal peritoneum lines
abdominal wall.
• Visceral peritoneum covers
organs.
• Peritoneal cavity is space
between parietal & visceral
layers.
• Contains serous fluid that reduces
friction between organs and
membranes.
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A&P: Peritoneum, Musculature, & Connective Tissue
• Rectus abdominis muscles
form anterior border.
• Vertebral column and
lumbar muscles form
posterior border.
• Internal and external
oblique muscles provide
lateral support
• External oblique aponeurosis is strong membrane covering entire
ventral surface of abdomen; lies superficial to rectus abdominis.
• Fibers from both sides interlace in midline to form linea alba.
• Linea alba is tendinous band protecting midline of rectus abdominis muscles
from xiphoid process to symphysis pubis.
• Diaphragm forms superior border of abdomen.
• Superior aperture of lesser pelvis forms inferior border.
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Anatomy & Physiology:
Alimentary Tract
• Alimentary tract extends from mouth
to anus, 27 feet (8.2 meters) & includes:
• Esophagus
• Stomach
• Small and large intestines
• Rectum
• Anal canal
• Main functions are to:
• Ingest and digest food.
• Absorb nutrients, electrolytes, and water.
• Excrete waste products.
• Peristalsis moves products of digestion:
• Controlled by autonomic nervous system.
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Anatomy and Physiology:
Esophagus
• A tube about 10 inches long.
• Connects pharynx to the stomach.
• Usual pH is between 6 and 8.
• Esophageal contents enter
stomach through lower
esophageal sphincter and mix
with digestive enzymes and
hydrochloric acid.
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Anatomy and Physiology: Stomach
• Hollow, flask-shaped,
muscular organ directly below
diaphragm in LUQ.
• Esophageal contents enter stomach
through lower esophageal sphincter
& mix with digestive enzymes & HCL.
• Gastric acid continues breakdown of carbohydrates that begin
in mouth.
• Pepsin breaks down proteins to peptones & amino acids.
• Gastric lipase acts on emulsified fats—triglycerides to fatty acids or
glycerol.
• Liquefies food into chyme & moves it into duodenum of small intestine.
• Usual pH of stomach from 2 to 4.
• Pyloric sphincter regulates outflow of chyme into duodenum.
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Anatomy & Physiology: Small Intestine
• Longest section of alimentary tract is about 21 feet.
• Begins at pyloric orifice, joins large intestine at ileocecal valve.
• Ingested food mixed, digested, and absorbed.
• Divided into three segments:
• Duodenum occupies first foot (30 cm) and forms C-shaped curve
around head of pancreas.
• Jejunum (8 feet long) and ileum (12 feet long) provide absorption
through intestinal villi.
• Ileocecal valve, between ileum and large intestine, prevents
backward flow of fecal material.
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A&P: Large Intestine (Colon) & Rectum
• Large intestine is 5 feet long & consists of cecum, appendix,
colon, rectum, & anal canal.
• Ileal contents empty into cecum via ileocecal valve.
• Appendix extends from base of cecum.
• Colon is divided into three parts: ascending, transverse, &
descending.
• End of descending colon turns medially
and inferiorly to form S-shaped sigmoid
colon.
• Rectum extends from sigmoid colon
to pelvic floor, continues as anal
canal, ends at anus.
• Large intestine absorbs water and electrolytes.
• Feces formed in large intestine and held until defecation.
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A&P: Accessory Organs
• Accessory organs of
GI tract:
•
•
•
•
Salivary glands
Liver
Gallbladder
Pancreas
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A&P: Liver
• Liver is largest organ (weighing 3.5 pounds) in body.
• Under right diaphragm, from fifth intercostal space to below costal
margin.
• Substantial portion covered by rib cage, only lower margin exposed
beneath it.
• Composed of right and left lobes.
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A&P: Liver
• Liver functions:
• Bile production and secretion
to emulsify fat.
• Transfer of bilirubin from blood
to duodenum.
• Metabolism of proteins, carbohydrates, and fats
• Storage of glucose in form of glycogen.
• Production of clotting factors and fibrinogen for coagulation.
• Synthesis of plasma proteins (albumin/globulin).
• Detoxification of substances, including drugs and alcohol.
• Storage of minerals (iron and copper) and vitamins (A, B12, and B-
complex vitamins).
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A&P: Gallbladder
• Gallbladder is pear-shaped sac, 3 inches long, inferior to
surface of liver.
• Concentrates and stores bile produced in liver.
• Cystic duct joins hepatic duct, forming common bile duct
that drains bile into duodenum.
• Bile in feces causes brown color.
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A&P: Pancreas
• Pancreas located in upper left abdominal cavity, under left
lobe of liver, behind stomach.
• Has both endocrine and exocrine functions:
• Endocrine secretions include
insulin, glucagon, & gastrin
for carbohydrate metabolism.
• Exocrine secretions contain
bicarbonate and pancreatic
enzymes that break down
proteins, fats, and carbohydrates
in duodenum for absorption.
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A&P: Spleen
• Spleen is highly vascular,
concave, encapsulated organ
in upper left quadrant of
abdomen.
• Part of lymphatic system,
composed of two systems:
• White pulp consisting of lymphatic
nodules and diffuse lymphatic
tissue.
• Red pulp consisting of venous
sinusoids.
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A&P: Spleen
• Functions of spleen:
• Storage of 1% to 2% of erythrocytes and platelets.
• Macrophages remove old and agglutinated erythrocytes and
platelets.
• Activation of B and T lymphocytes.
• Production of erythrocytes during bone marrow depression.
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A&P: Urinary Tract
• Kidneys, ureters, urinary bladder,
and urethra work together to
remove water-soluble wastes.
• Kidneys:
• Located in posterior abdominal cavity on either side, covered by
peritoneum and attached to posterior abdominal wall.
• Partially protected by ribs and cushion of fat and fascia.
• Right kidney slightly lower than left, due to displacement by liver.
• Kidney functions include:
• Secretion of erythropoietin to stimulate red blood cell production.
• Secretion of renin to activate renin-angiotensin-aldosterone system
(constricts blood vessels and affects blood pressure).
• Production of biologically active form of vitamin D.
• Nephron regulates fluid and electrolyte balance through elaborate
microscopic filter and pressure system that eventually produces urine.
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A&P: Ureters & Bladder
• Ureters:
• Urine forms in nephron, flows from distal tubes
& collecting ducts into ureters and into bladder.
• Composed of long, intertwining muscle bundles
extending 12 inches to insertion at base of bladder.
• Bladder, a sac of smooth muscle fibers, behind symphysis
pubis in anterior half of pelvis.
• Contains internal sphincter that relaxes when bladder full.
• When bladder’s volume reaches about 300 mL, moderate
distention is felt; a level of 450 mL causes discomfort.
• For voiding to occur, external sphincter relaxes voluntarily, and
urine exits through urethra, which extends out of base to external
meatus.
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A&P: Vasculature of the Abdomen
• Descending aorta travels through
diaphragm and branches into two
common iliac arteries at level of
umbilicus.
• Kidney perfusion provided by right
and left renal arteries that branch off
descending aorta.
• Blood from abdomen returned to right
side of heart by inferior vena cava.
• Several veins empty into inferior vena
cava.
• Hepatic portal system: Veins draining
intestines, pancreas, stomach, and
gallbladder.
• Renal veins drain kidneys and ureters.
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ABDOMINAL
ASSESSMENT
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General Health History:
Present Health Status
• Any chronic diseases that affect your GI or urinary
systems?
• Do you take any medications?
• What, and how often?
• Taking as prescribed?
• How often do you have a bowel movement?
• What are color and consistency of stool?
• NEVER underestimate the importance of this!!!
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General Health History:
Past Medical History
• Have you had problems with abdomen or digestive
system?
• Surgery of abdomen or urinary tract?
• Change in routines, changes in food, or bowel or urinary
elimination?
• Able to cope with the presence of ostomy?
• Have you had problems with your urinary tract in the past?
•
• Do you experience leakage of urine?
• When does this occur?
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General Health History:
Family History
• Family history of diseases of GI system:
• Gastroesophageal reflux disease (GERD)?
• Peptic ulcer disease?
• Stomach or colon cancer?
• Family history of diseases of urinary tract such as kidney
stones?
• Kidney or bladder cancer?
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General Health History:
Personal and Psychosocial History
•Do you smoke?
•Do your drink alcohol?
• How much?
• How often?
• How much?
• How long have you been
smoking?
• Have you considered
stopping?
• How long have you been
smoking?
• Have you considered
stopping?
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Problem-Based History: Abdominal Pain
• How long have you had pain?
• Where?
• When did you first feel pain?
• Constant or intermittent? Had episodes
before?
• Did pain start suddenly?
• Changed location?
• Felt elsewhere?
• Worse when stomach empty?
• Affected by eating?
• Worse at night or day?
• Women: Associated with menstrual
period?
• Last menstrual period?
• Could you be pregnant?
• Pain associated with other
symptoms?
• Stress?
• Fatigue?
• Nausea and vomiting?
• Gas?
• Constipation or diarrhea?
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Problem-Based History: N&V
• Nausea or vomiting for how long?
• Frequency?
• How much vomit?
• What does it look like?
• Contain blood?
• Do you have nausea without
vomiting?
• Foods eaten in last 24 hours?
• How long after eating did you
vomit?
• Anyone else had these
symptoms over same period?
• Other symptoms:
• Pain?
• Constipation?
• Diarrhea?
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Problem-Based History: Indigestion
• Indigestion or heartburn for how long?
• Stomach?
• Chest?
• What makes it worse?
• Change of position?
• What relieves pain?
• Antacids or acid blockers?
• Other symptoms:
• Radiating pain?
• Sweating?
• Lightheadedness?
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Problem-Based History:
Abdominal Distention
• How long have you had it?
• Does it come and go?
• Is it related to eating?
• What relieves it?
• Other symptoms:
• Vomiting?
• Loss of appetite?
• Weight loss?
• Change in bowel habits?
• Shortness of breath?
• Pain?
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Problem-Based History:
Change in Bowel Habits
• Describe change.
• When did you first notice change?
• Changed diet?
• What does stool look like?
• Bloody, mucoid, fatty, watery?
• Other symptoms:
• Increased gas?
• Pain?
• Nausea or vomiting?
• Abdominal cramping?
• Diarrhea?
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Problem-Based History: Yellow
Discoloration of Eyes or Skin (Jaundice)
• First noticed when?
• Has it become more noticeable?
• Associated with abdominal pain?
• Loss of appetite
• Nausea or vomiting?
• Blood transfusion or tattoos in past
year?
• Use intravenous drugs?
• Eat raw shellfish such as oysters?
• Traveled abroad in last year?
• Has color of your urine or stools
changed?
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Problem-Based History:
Problems with Urination
• Usual pattern of urination?
• Pain or burning?
• Frequency or urgency?
• Associated symptoms:
• Fever?
• Chills?
• Back pain?
• Blood in urine?
• Unexpected weight gain?
• Swelling in ankles at end of day or shortness of breath?
• Urinating less?
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ABDOMEN:
PHYSICAL EXAM
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Physical Exam
• OBSERVE
• General behavior and position
• INSPECT
• Abdomen
• AUSCULTATE
• All 4 quadrants
• PALPATE
• Light palpation ONLY
• PERCUSS
• Abdomen
• Liver, spleen, kidneys
• Other
• Assess fluid, pain r/t inflammation, floating mass, abdominal reflexes
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INSPECT: general appearance & position
• Observe patient’s general behavior and position.
• Inspect abdomen for skin color, surface characteristics,
contour, and surface movements.
• Surface characteristics should be smooth, with centrally located
umbilicus.
• Striae, scars, faint vascular network.
• Contour usually sunken; slight
protrusion if overweight or obese.
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AUSCULTATE
• Auscultate abdomen for bowel sounds:
• Use diaphragm of stethoscope lightly and listen in a systematic
progression.
• Auscultate abdomen for arterial and venous vascular
sounds:
• Use bell of stethoscope over aorta, renal, iliac, and femoral arteries
for bruits.
• Use bell over epigastric area or around umbilicus for venous hum.
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PALPATE
• Palpate abdomen lightly for tenderness,
muscle tone, and surface characteristics.
• No tenderness should be present, and the
abdominal muscles should be relaxed.
• Palpate abdomen deeply for tenderness, masses, and
aortic pulsation. NO- for advanced practice only.
• Observe for facial grimaces that indicate areas of tenderness; ask
patient to breathe slowly through mouth to facilitate muscle
relaxation; when patient has abdominal pain, palpate over area of
pain last.
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Purcussion & common tests
• Percuss all quadrants of abdomen
using indirect percussion to assess
density of abdominal contents.
• Assess abdomen for fluid, if fluid is
suspected.
• Assess abdominal pain due to
inflammation.
• Test for rebound tenderness.
• McBurney’s sign: Test for appendicitis.
• Iliopsoas muscle test: If acute
appendicitis suspected.
• Obturator muscle test: If ruptured
appendix or pelvic abscess suspected.
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Tests for Ascites
Shifting Dullness
Fluid Wave
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Tests for Appendicitis
Rebound Tenderness
McBurney’s Sign
Iliopsoas Muscle Test
Obturator Muscle Test
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Special Circumstances & Advanced Practice
• Percuss liver to determine span and descent.
• Liver span correlates with body size and gender; large people and
men tend to have larger spans; lower border of liver should descend
downward 0.75 to 1.25 inches (2 to 3 cm).
• Percuss spleen for size.
• Note whether tympany changes to dullness on inspiration; enlarged
spleen is brought forward on inspiration to produce a dull percussion
note.
• Palpate around umbilicus for bulges, nodules, and umbilical
ring.
• Ring should be round with no irregularities or bulges.
• Umbilicus should be inverted or slightly everted.
• Palpate liver for lower border and tenderness.
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Special Circumstances & Advanced Practice
• Palpate gallbladder for tenderness.
• Palpate spleen for border and tenderness.
• Palpate kidneys for presence, contour,
and tenderness.
• Elicit abdominal reflexes for presence.
• Percuss kidneys for costovertebral
angle tenderness.
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Special Circumstances & Advanced Practice
• Assess abdomen for floating mass.
• Ballottement is palpation technique used to determine a floating
mass.
• Ballottement can be performed with one or both hands.
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Age-Related Variations:
Infants, Children, and Adolescents
• Assessment techniques are
same for infants, children, and
adolescents.
• There are several differences in
assessment findings in infants
based on anatomic differences.
• Children and adolescents may
resist abdominal palpation
because they are ticklish.
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Age-Related Variations:
Older Adults
• Procedures and techniques for assessing GI and renal
systems of older adults are same as for younger adults.
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PATHOPHYSIOLOGY
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GERD
• GERD:
• Flow of gastric secretions up
into esophagus.
• Weakened lower esophageal pressure
or increased intraabdominal pressure.
• Clinical findings:
• Heartburn
• Regurgitation
• Dysphagia
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Hiatal Hernia
• Hiatal hernia:
• Protrusion of stomach through esophageal hiatus of diaphragm into
mediastinal cavity.
• Muscle weakness is a primary factor.
• Pregnancy, obesity, and ascites.
• More common in women and older adults.
• Clinical findings:
• Clinical manifestations are same as those of GERD:
• Heartburn
• Regurgitation
• Dysphagia
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Peptic Ulcer Disease
• Peptic ulcer disease is ulcer occurring in lower end of esophagus,
stomach, or duodenum.
• Duodenal ulcer most common, from break in mucosa that forms scar.
• Gastric and duodenal ulcers may result from infection with Helicobacter pylori
infection.
• Gastric ulcers also caused by stress, medications (corticosteroids, aspirin,
nonsteriodal antiinflammatory drugs [NSAIDs]).
• Patients complain of burning after eating.
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Crohn’s Disease
• Crohn’s disease—chronic inflammatory bowel disease
(IBD)—is also called regional enteritis or regional ileitis.
• Inflammation may occur from mouth to anus; commonly affects
terminal ileum and colon.
• Affected mucosa ulcerated with fistulas, fissures, and abscesses.
• Clinical findings:
• Patients complain of severe abdominal pain, cramping, diarrhea,
nausea, fever, chills, weakness, anorexia, and weight loss.
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Ulcerative Colitis
• Ulcerative colitis, a chronic IBD, starts in rectum and
progresses through large intestine.
• Submucosa becomes engorged; mucosa ulcerated and denuded
with granulation tissue.
• May progress to colon cancer.
• Clinical findings:
• Patients complain of severe abdominal pain, fever, chills, anemia,
and weight loss.
• Patient experiences profuse watery diarrhea of blood, mucus, and
pus.
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UC vs Crohn’s
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Diverticulitis
• Diverticulitis is inflammation of diverticula, herniations
through muscular wall in colon.
• Presence of fecal material through thin-walled diverticula causes
inflammation and abscesses.
• Clinical findings:
• Patients complain of cramping pain in the lower left quadrant,
nausea, vomiting, and altered bowel habits, usually constipation.
• Abdomen distended and tympanic; decreased bowel sounds and
localized tenderness.
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Viral Hepatitis
• Viral hepatitis: Inflammation of liver from viruses.
• Clinical findings:
• Common symptoms: Anorexia, vague abdominal pain, nausea,
vomiting, malaise, and fever.
• Enlarged liver and spleen are classic findings.
• Liver inflammation may alter bilirubin conjugation so that patient’s
sclera and skin are jaundiced, stools appear clay-colored, and
urine is dark amber.
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Cirrhosis
• Cirrhosis is chronic degenerative liver disease; causes
include viral hepatitis, biliary obstruction, alcohol abuse.
• Clinical findings:
• Liver becomes palpable and hard.
• Associated signs: Ascites, jaundice, cutaneous spider angiomas,
dark urine, clay-colored stools, and spleen enlargement.
• End-stage cirrhosis is hepatic encephalopathy and coma.
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Cholecystitis
• Cholecystitis with cholelithiasis:
• Inflammation of gallbladder
(cholecystitis); with gallstones (cholelithiasis)
• Bile duct becomes obstructed either by edema from inflammation
or by gallstones.
• Clinical findings:
• Primary symptom is right upper quadrant colicky pain that may
radiate to mid-torso or right scapula.*
• Indigestion and mild transient jaundice.
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Pancreatitis
• Pancreatitis is acute or chronic inflammation from
autodigestion.
• Flow of pancreatic digestive enzymes into duodenum obstructed;
digestive enzymes act on pancreas itself.
• Caused by alcoholism or by obstruction of sphincter of Oddi by
gallstones.
• Clinical findings:
• Pain: Steady, boring, dull, or sharp;
radiates from epigastrium to back.
• Patients prefer fetal position with
knees to chest.
• Nausea and vomiting.
• Weight loss.
• Steatorrhea.
• Glucose intolerance
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Urinary Tract Infection
• Urinary tract infections may involve urinary bladder
(cystitis), urethra (urethritis), or renal pelvis
(pyelonephritis).
• Most UTIs result from gram-negative organisms, such as
Escherichia coli, Klebsiella, Proteus, or Pseudomonas,
that originate from patient’s own intestinal tract and
ascend through urethra to bladder.
• Clinical findings of UTIs:
• Symptoms of urethritis include frequency, urgency, and dysuria.
• Symptoms of cystitis include the above, plus signs of bacteriuria
and perhaps fever.
• Patients with pyelonephritis complain of flank pain, dysuria,
nocturia, and frequency.
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Nephrolithiasis
• Nephrolithiasis is formation of stones in kidney pelvis.
• Stones, or calculi, are made of calcium salts, uric acid, cystine, or
struvite.
• Alkaline urine facilitates formation of stones made of calcium
phosphate; acid urine facilitates stones formed of cystine.
• Clinical findings:
• Signs include fever and hematuria.
• A symptom is flank pain that may radiate to groin and genitals.
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Question 1
A nurse practitioner is performing a routine check-up on an
adult male. As the nurse begins the abdominal
assessment, the nurse knows to:
A.
B.
C.
D.
Begin with observation of the patient’s general behavior.
Begin with palpation if the patient is in pain.
Ask the patient if he has noted any vascular sounds in
the abdomen before.
Ask the patient to straighten his legs for the abdominal
exam.
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Question 2
When percussing the kidneys for tenderness, the nurse
should:
A.
B.
C.
D.
Start tapping at the level of T1.
Tap in the costal angle.
Use the direct or indirect method of percussion.
Know whether the patient has a history of cholelithiasis.
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Case Study
Sylvan is a 44-year-old male who works at the local grocery
store. His four children live in his home with him. He has a
history of hypertension and erectile dysfunction. He and
his wife have been married for 14 years.
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Case Study (contd.)
• Subjective data:
• Complains of gas, belching, and food regurgitation after
eating, especially spicy foods.
• This has existed for at least 2 months.
• Rolaids help, but his condition seems to be getting worse.
• Objective data:
• Vital signs: T 98.2; P 71; R 8. Height: 6’4”; Weight 300 lb.
• Lungs: Clear, no wheezing or rales present.
• Heart: RRR, no murmurs.
• GI: ABD: Soft + BS all four quadrants.
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Case Study (contd.)
• Questions:
1.
What risk factors does Sylvan have for GERD?
2.
What measures might have helped prevent GERD?
3.
What should the nurse do in this clinical situation? Prioritize
actions.