GIT assessment & PE

Gastrointestinal SystemAssessment & Diagnostic Studies

Margaret Xaira R. Mercado RN

ASSESSMENT

A. Health History

1. Past health history2. Medications (past, present, over-

the-counter, herbs)3. Surgeries

Physical Examination

1. Inspectiona. Mouth – symmetry, color, size, odor, teethb. Abdomen – skin changes, symmetry, contour, masses, movement

1) peristalsis is only visible in a thin adult

2) aortic pulsation may be seen in the epigastric regionc. Rectum and anus – color, lumps, tissues, external hemorroids

Physical Examination

2. Auscultationa. Bowel sounds

1) perform prior to percussion and palpation

2) auscultate all 4 quadrants3) high – pitched gurgling

occuring every 5 to 15 seconds4) listen 5 minutes to all four

quadrants before determining absenceb. Aortic bruit indicate turbulent blood flow

Physical Examination

3. Percussiona. Detrmines pressence of fluid, distention, and massesb. Liver 2.4 to 5 inches (6-12 cm) dullness at the right midclavicular linec. Tympany predominant sound of the abdomen

Physical Examination4. Palpation

a. Mouth – ulcers, indurations, tendernessb. Abdomen1) light palpation (1cm) – detects tenderness,

masses, swelling, muscular resistance, cutaneous hypersensitivity

2) deep palpation (4-6cm) – outlines abdominal organs and masses

3) round tenderness – indicates peritoneal inflammation

4) liver – may be felt 0.4 to 0.8 inch (1 to 2 cm) below the right costal margin

5) spleen – felt only if enlarged, rupture can occur if continued

DIAGNOSTIC STUDIES

UPPER GI orBARIUM SWALLOW

• X-ray study with flouroscopy and contrast medium (barium)

PREPROCEDURE1. NPO for 8 to 12 hours2. No smoking

POSTPROCEDURE1. Encourage 6 to 8 glasses of water daily2. Offer laxative – stools may be white for 72 hours

UPPER GI orBARIUM SWALLOW

LOWER GI or BARIUM ENEMA

• X-ray study visualizing the colonPREPROCEDURE

a. Day before the test1) clear liquid for lunch and dinner

2) 8 ounces of fluid every hour for 8 to 10 hours

3) 10 ounces of magnesium citrate or x-prep in mid to late afternoon

4) prescribed number of 5mg bisacodyl (Dulcolax) tablets – usually 3 or 4

5) maybe NPO after midnight

LOWER GI or BARIUM ENEMA

b. Day of the test:1) Bisacodyl (Dulcolax) suppository early

morning or tap water enema2) continue NPO or clear liquid diet up to the

procedure3) contrast medium (barium)

administered rectally with the client on a tilt table

POSTPROCEDUREa. Increase fluidsb. Offer laxative – stools may be white

for 72 hours

LOWER GI orBARIUM ENEMA

ORAL CHOLECYSTOGRAM(GB SERIES)

X-ray visualization of the gallbladder to determine the patency of the biliary duct system while assessing the ability of the gallbladder to concentrate, contract and empty

PREPROCEDUREa. Day before the test:1) assess for allergy to iodine or

seafood2) evaluate the bilirubin level – if

greater than 2mg/dl, will not visualize the gallbladder

3) low-fat or fat-free meal for dinner4) six radiopaque iopanoic acid

(Telepaque) tablets are administered 5 minutes apart beginning 2 hours after dinner

ORAL CHOLECYSTOGRAM(GB SERIES)

5) inform the radiologist if vomiting or diarrhea occurs after ingestion of the dye

6) NPO after ingestion of the dye

POSTPROCEDUREa. May be given fatty meal to enhance excretion of the dyeb. Assess for slight dysuria as the dye is excreted

CHOLANGIOGRAMX-ray visualization of the hepatic and common bile

ductsPREPROCEDUREa. Day before the test

1) assess for allergy to iodine or seafood2) evaluate the bilirubin level –

contraindicated if greater than 3.5 mg/dl

b. Day of the test1) NPO after midnight2) radiographic dye is

administered intravenously

CHOLANGIOGRAM

POSTPROCEDUREa. Two to 6 hours after the test, assess

for delayed reaction to the dye (dyspnea, rashes, tachycardia, hives)

b. Assess for slight dysuria as the dye is excreted

PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAM

X-ray visualization of the intrahepatic, extrahepatic billiary ducts and occasionally, the gallbladder after direct administration of the radiopaque dye into the intrahepatic duct

Useful in clients who are jaundicedPREPROCEDUREa. assess for allergy to iodine or seafoodb. evaluate coagulation studiesc. type and cross match the bloodd. NPO after midnight

PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAM

POSTPROCEDUREa. maintain bed rest for several hoursb. assess for bleeding and sepsisc. monitor vital signsd. avoid analgesics to prevent covering up abdominal signs associated with bile leakage or hemorrhage

UPPER GI ENDOSCOPY(Esophagogastroduodenoscopy)

Direct visualization of the upper gastrointestinal tract using a long, flexible, fiberoptic-lighted scope

PROCEDUREa. Day before the test

1) NPO after midnight2) Remove the client’s dentures and other oral devices3) Inform the client that speaking during the procedure is not possible because of the fiberscope

UPPER GI ENDOSCOPY(Esophagogastroduodenoscopy)

b. Day of the test1) Client is placed on left lateral decubitus position to facilitate easier insertion of the endoscope2) Topical anesthetic spray naloxone (Xylocaine) is applied to the throat to inactive the gag reflex3) Atropine may be given to reduce secretions4) Glucagon may be given as a smooth muscle relaxant5) Biopsies may be taken if indicated

UPPER GI ENDOSCOPY(Esophagogastroduodenoscopy)

POSTPROCEDUREa. Maintain on NPO until gag reflex

returns, usually 2 to 4 hoursb. Assess the gag reflex by tickling the

back of the throatc. Monitor for signs of perforation

(bleeding, abdominal pain, elevated temperature, dyspnea, or dysphagia)

d. Offer warm saline gargles or throat lozenges for relief of sore throat

e. Maintain bed rest with the side rails elevated until sedation wears off.

UPPER GI ENDOSCOPY(Esophagogastroduodenoscopy)

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREOTOGRPHY

Radiographic visualization of the common bile and pancreatic ducts with the use of fiberoptic endoscope

PREPROCEDUREa. Day before the test

1) NPO after midnight2) Inform the client that breathing will not be compromised with the endoscope3) Instruct the client that lying very still is essential to allow for good visualization of the ducts

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREOTOGRPHY

b. Day of the test1) Remove the client’s dentures2) Sedative with narcotic is administered for relaxation

3) Client is placed in supine left lateral position to facilitate insertion of the endoscope

4) Topical anesthetic spray, naloxone (Xylocaine) is applied to the pharynx to inactive the gag reflex

5) Place the client in several positions throughout the procedure to permit passage of a small catheter into the ductal system for the injection of

radiographic dye so x-ray films may be taken6)Glucagon is often administered to

minimize spasms and improve visualization of the ampulla of Vater

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREOTOGRPHY

POSTPROCEDUREa. Maintain NPO until gag reflex returnsb. Monitor for signs of ERCP-induced

pancreatitis (abdominal pain, nausea, and vomiting)

c. Monitor for signs of ERCP-induced cholangitis (septicemia)

d. Offer warm saline gergles or throate. Maintain bed rest with side rails

elevated until sedation wears off

ENDOSCOPIC RETROGRADE CHOLANGIOPANCREOTOGRPHY

COLONOSCOPY

Direct visualization of the entire colon from the anus to the cecum with a flexible fiberoptic scopePD

PREPROCEDUREa. Day before the test

1)One gallon of GoLYTELY or Colace administered the evening before the

procedure (one glass every 10 minutes until gone)

2) Bisacodyl (Dulcolax) tablets and enemas may be given

3) clear liquid diet beginning at noon and up to 8 hours before the procdure, then NPO

COLONOSCOPY

b. Day of the test1) client is placed in left lateral decubitus position to insert the colonoscope2) Administer ordered sedative medication – usually Midazolam (Versed)

3) Atropine may be given to decrease colonic secretions

4) Client’s position will be changed to facilitate the colonoscope as it is directed toward the cecum

COLONOSCOPYPOSTPROCEDUREa. Maintain bed rest with side rails up until sedation

wears offb. Inform the client that abdominal cramping may

be experienced because air was injected into the colon during the procedure.

c. Monitor for signs of colon perforation (abdominal distention and tenderness)

d. Monitor vital signs for signs of hemorrhage (increased pulse and decreased blood pressure)

e. Offer food after assessing for evidence of bowel perforation

f. instruct the client to push fluids to compensate for dehydration from bowel preparation

COLONOSCOPY

PROCTOSIGMOIDOSCOPYDirect visualization of the anus, rectum, and sigmoid

colon with the use of a fiberscopePREPROCEDUREa. Day before the test

1) administer an enema evening before the procedure

b. Day of the test1) clear liquid breakfasr2) administer the enema the

morning of the procedure3) client is placed in the lateral

decubitus position and assisted into the knee-chest position during the procedure

PROCTOSIGMOIDOSCOPY

POSTPROCEDUREa. Inform the client that abdominal

discomfort and flatulence may be experienced because air was injected into the bowel during the procedure

b. Monitor for signs of rectal bleeding

LIVER BIOPSYInsertion of a needle between the sixth and

seventh or eighth and ninth intercostal space on the right side to obtain a specimen for hepatic tissue

PREPROCEDUREa. Day before the test

1) Obtain the client’s coagulation study (PT, clotting or bleeding time)

2) type and cross-match3) Obtain baseline vital signs4) Obtain informed consent

LIVER BIOPSY

b. Day of the test1) administer the prescribed sedative2) place the client in the supine or left lateral position3) instruct the client to exhale and hold the exhalation, allowing the liver to descend, decreasing the risk of a pneumothorax

LIVER BIOPSY

POSTPROCEDUREa. Placwe the client on right side for 1-

2 hours, pressing a liver capsule against the chest wall to decrease risk of hemorrhage

b. Monitor vital signs for evidence of hemorrhage I increase pulse, decreased blood pressure) and peritonitis (increased temperature)

LIVER BIOPSY

GASTRIC ANALYSISContents of the stomach are aspirated to

determine the amount of acid produced during the resting or basal state (basal acid output [BAO]) and during the stimulated state (maximal acid output {MAO])

PREPROCEDUREa. Day before the test

1) instruct the client not to smoke, chew gum, or take anticholinergic medications before the procedure

2) NPO after midnight

GASTRIC ANALYSIS

b. Day of the test1) Nasogastric tube is inserted with syringe attached to aspirate gastric contents and discard first specimen2) four subsequent samples are taken and analyzed every 15 minutes apart (these are BAO)3) histamine is administered subcutaneously and eight samples are taken and analyzed every 15 minutes minutes apart (these are MAO)4) inform the client that histamine may produce a flushing sensation

GASTRIC ANALYSIS

POSTPROCEDUREa. Monitor the client for histamine side

effects such as intestinal, bronchial, and uterine spasms.

GASTRIC EMPTYINGSTUDIES

Radionuclide studies in which the stomach is scanned until gastric emptying is complete after the ingestion of the “test meal” either solid or liquid containing technetium (Tc)

PREPROCEDUREa. Day before the test

1) NPO after midnight

GASTRIC EMPTYINGSTUDIES

a. Day of the test1) client ingests a solid “test meal” consisting of a cooked egg white containing Tc or a liquid “test meal” consisting of a glass of orange juice containing Tc2) inform the client that only a small dose of radionuclear material is ingestedand is safe3) place the client in a supine position and images are taken under a gamma camera every 2 minutes depending on emptying time

GASTRIC EMPTYINGSTUDIES

POSTPROCEDUREa. Instruct the client that no rradiation

precautions need to be taken in the disposal of bodily secretions

b. Reinforce safety of the dose of the radioactive material

STOOL SPECIMEN

FECAL FAT – stool is collected continously foe 3 days and fecal fat is measured to evaluate pressence of malabsorption

PREPROCEDURE Three day collection

1) 100g of fat ingested per day for 3 days

2) instruct the client to defacate in clean dry container and to avoid urinating or placing toilet paper in the container

3) instruct the client to avoid laxatives or enemas during the test

STOOL SPECIMEN

4) send each stool specimen to the lab immediately in an acute care setting, or instruct the client to keep all stool container in the freezer at home until completion of the test

POSTPROCEDURE1) Instruct the client to resume a

normal diet

STOOL SPECIMEN

OCCULT BLOOD – stool sample is obtained to determine presence of gastrointestinal bleeding

PREPROCEDURE1) Instruct the client to avoid red meats, raw vegetables, fruits and vitamin C for 3 days before the test

2) instruct the client to avoid taking nonsteroidal anti-inflammatory drugs, anticoagulants, and steroids for 7 days before

the test3) instruct the client to defacate

in an appropriate container, keeping the stool specimen free from urine or toilet paper

Types of tests foroccult blood

HEMOCULT TEST1) Open the front cover of the Hemoccult

slide and apply a thin smear of stool2) open the back cover of the Hemoccult

slide and apply two drops of developer on the slide

3) bluish discoloration indicates presence of occult blood

Types of tests foroccult blood

HEMATEST1) place a small smear of stool on the guiac filter paper2) put a Hematest tablet in the middle of the stool sample3) place 2 or 3 drops of water on the tablet4) bluish discolorration indicates pressence of occult blood

STOOL FOR OCCULT BLOOD

POSTPROCEDUREa. Resume normal diet and medicationsSTOOL CULTURE – stool sample is obtained to

determine presence of a bowel infectionPROCEDURE1) Instruct the client not to void urine

with stool sample2) Dip a sterile swab into the purulent

fecal matter and then place the swab in a sterile test tube

3) Send the specimen immediately to the lab

UREA BREATH TESTBreath sample taken after ingestion of carbon –

labeled urea capsule to determine presence of Helicobacter pylori

PREPROCEDUREa. Instruct the client to avoid loperamide (Pepto-

Bismol) and antibiotics for 1 month prior to the test

b. Instruct the client to avoid omeprazole (Prilosec), lansoprazole (Prevacid), or esomeprazole (Nexium) for 1 week

c. Instruct the client to avoid nizatidine (Axid), ranitidine (Zantac), famotidine (Pepcid), or cimetidine (Tagamet) for 24 hours prior to the test

UREA BREATH TEST

PROCEDUREa. Client ingests a carbon labeled urea

capsuleb. Breath sample is taken 10-20

minutes later

PARACENTESISInsertion of a needle into the peritoneal cavity to

remove ascitic fluidPREPROCEDUREa. Instruct the client to empty the bladder (prevents

accidental trauma from the needle during the provedure)

b. Measure the abdominal girthc. Obtain the client’s weightd. Obtain baseline vital signse. Place the client in a high-Fowler’s

position in the bed or in a chair with the back supported and feet flat on a stool

PARACENTESIS

POSTPROCEDUREa. Monitor vital signsb. Measure and compare preprocedure

weight and abdominal girthc. Monitor serum protein and

electrolyte levels because of high albumin and electrolytes, especially sodium

d. Monitor dressing over the needle puncture site for bleeding

PARACENTESIS

BLOOD CHEMISTRIES

•Decreased in chronic liver disease or malabsorption

Albumin

•Elevated in severe liver disease

Ammonia•Ele

vated in acute pancreatitis

Amylase

•Elevated in biliary obstruction or impaired liver function

Bilirubin

•Decreased in acute pancreatitis or malabsorption syndrome

Calcium

•Elevated in biliary obstruction or extensive liver disease

Cholesterol

BLOOD CHEMISTRIES

•Elevated in pancreatic insufficiency

•Decreased in pancreatic hypofunction, tumor, or dumping syndrome

Glucose (fasting)

•Elevated in metastatic cancer of the liver

Lactic Dehydrogenase (LDH)

•Elevated in acute pancreatitis, liver disease, or perforated peptic ulcer

Lipase

•Elevated in biliary obstruction

Phosphatase, Alkaline

•Decreased in severe diarrhea, vomiting, starvation, fistula along GI tract, or pyloric obstruction

Potassium

•Elevated in cirrhosis

•Decreased in other liver disease or malabsorption

Protein

BLOOD CHEMISTRIES

•Decreased in severe diarrhea or vomiting

Sodium

•Elevated in acute hepatitis

Serum Glutamicoxaloacetic (SGOT) or Aspartate Aminotransferase (AST)

•Elevated in liver disease

Serum Glutamate Pyruvate (SGPT) Alanine Aminotransferase (ALT)

•Elevated in liver disease

•Decreased in malnutrition

Triglycerides

•Decreased in malnutrition or severe liver damage

Urea Nitrogen (BUN)

•Decreased in pernicious anemia or after gastrectomy

Vitamin B12