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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