Upon completion of this chapter, the nurse will:
1. Outline the areas to include when assessing the gastrointestinal system
2. Identify appropriate questions to assess the gastrointestinal system
3. Analyze approaches to gather more information about the gastrointestinal system
THE GASTROINTESTINAL SYSTEM
The primary function of the gastrointestinal system is digestion. The organs and structures within the system are extensive and include:
The organs of digestion need assistance for food to be absorbed and utilized by the body. These accessory organs include:
As a review, after swallowing food that is chewed in the mouth, it travels through the esophagus to the stomach where it begins to be broken down and converted into a substance called chyme. Once chyme enters the small intestine, it is further broken down by enzymes secreted by the liver, gallbladder, and pancreas in preparation for being absorbed. Once all potential substances are absorbed, the residue from the food is advanced to the beginning of the large intestine where any additional water from the food residue is absorbed. At the completion of this entire process, the remnants of ingested food are eliminated in the stool.
Although this process sounds easy, many things impact a well-functioning gastrointestinal system. First of all, a person needs to have an appetite in order to seek food. Then, adequate dentition and sufficient saliva are needed to wet the food and begin the breaking down process. The esophagus needs to be intact with a functioning cardiac sphincter to prevent food from backing up from the stomach. The stomach needs to have sufficient hydrochloric acid to prepare chyme and an intact pyloric sphincter to prevent reflux of chyme once it advances into the small intestine. The liver, gallbladder, and pancreas need to be functioning at a high level in order to break down proteins, carbohydrates, and fats for body absorption. And the large intestine needs to be clear and free of inflammation in order to adequately remove food residue from the body.
Because the gastrointestinal system involves many parts and body organs, it is best to approach the assessment methodically. As with other body organs, the traditional methods to assess this system telephonically are different. You will need to focus on thoughtful questioning and careful listening when completing the assessment of this body system.
Keep in mind that you will not be able to:
Inspect the condition of the oral cavity including dentition
Auscultate bowel sounds
Palpate the abdomen
Percuss the abdomen
Observe the color of emesis or stool
Test stool for occult blood
Further assess stool for steatorrhea
Observe skin color for jaundice
Because the organs within this system are grouped as primary and accessory, assessment can occur following the same approach. Remember that most people do not like to spend time discussing their digestion and bowel function. For some, this can be uncomfortable, and a patient/client may provide short answers without divulging what they consider intimate information. A “matter of fact” conversational approach is recommended to gather the most quality information.
QUESTIONS TO ASSESS THE GASTROINTESTINAL SYSTEM
As with other system assessments, begin by asking if the patient has had any problems with eating or digesting food. If the answer is “no,” you can conduct a general assessment of all major gastrointestinal organs. You can begin the assessment of this system by introducing the questioning with a general statement such as:
“I’m glad to hear that you don’t have any issues with eating or digestion. Let’s just take a few minutes anyway and go over some specific areas.”
Some seasoned telephonic nurses like to begin the assessment of the gastrointestinal system by asking the patient for his or her height and current weight. From this information, the nurse then proceeds into the general questions. This approach is appropriate for some patients but not for others. Use your best judgment. There is no “right or wrong” time to gather height/weight information.
Do you have any problems chewing food?
Do you have all or most of your teeth? If not, do you have:
A partial plate?
If dentures, are they:
Are you experiencing any sores or bleeding of your gums from the dentures?
Do you have any problems with swallowing fluid or food? If so, do you:
Cough when you swallow food or fluid?
Does it ever feel like food gets “stuck” in your throat after swallowing? If so,
What do you do to help this?
Eat more food?
Drink some fluid?
Have you ever been diagnosed or told that you have a stomach problem?
Do you ever experience pain or burning from your stomach? If so,
Does the pain/burning occur before eating?
If it occurs after eating, how long after eating does the pain occur?
Do you take any medicine for your stomach? Is it for:
Vitamin supplement? (Vitamin B12, iron)
Indigestion? (chewable tablets)
Have you noticed any change in your appetite? Describe the change such as:
No desire to eat
Desire to eat only one type of food
Appetite has been increasing with no associated weight gain
Weight gain despite not ingesting a routine amount of food
How long is it between meals before you start to feel hungry again?
When you feel hungry do you seek food to eat or do you ignore the hunger and eat later?
How long do you wait after hunger pains to eat?
How many meals do you eat a day?
How many snacks do you eat a day?
Does nausea ever prevent you from eating? If so,
How often would you say you are nauseated?
Do you ever vomit after feeling nauseated?
How often does this occur?
Are there any foods that cause you to become immediately ill? If so,
What are the foods?
Have you been told you have food allergies?
What happens if you eat a food that you are allergic to?
What do you do if you accidentally eat a food that you are allergic to?
Have you ever had testing done for your stomach such as
Scope of your stomach to look at the lining?
Do you ever experience a burning sensation around your belly button? If so,
What do you do when this happens?
Have you talked with your doctor or health care provider about it?
Do you ever hear your stomach gurgling? If so,
Do you hear it a lot?
When does it most often occur?
Does anything else happen when the gurgling occurs such an episode of diarrhea or the need to have a regular bowel movement?
Do you ever feel like your abdomen or belly is swollen or bloated? If so,
How often does this occur?
What makes it better?
Do you take any medicine for the bloating?
Have you talked about this with your doctor or health care provider?
Have you ever had testing done on your small intestine such as:
Are you currently experiencing any problems with your bowels?
How often do you have a bowel movement?
What is considered a normal bowel movement frequency for you?
Describe the color and shape of your routine bowel movement.
Does the shape of your bowel movement ever change, such as:
Thin like a pencil?
Small hard round pieces?
Does your bowel movement ever seem:
Lighter in color than usual?
Darker in color than usual?
Does your bowel movement ever have particles of undigested food in it?
Do you have any problems with having a routine bowel movement? If so,
Is the stool hard and difficult to pass?
Is the stool runny?
Does the stool have a strong or odor that is unusual for you?
Do you ever have obvious blood in or around your stool?
Does your stool ever look black and sticky like tar?
Do you ever experience diarrhea? If so,
Does anything make it happen?
Do you have any pain with it?
Do you take anything over-the-counter to make it stop?
Have you talked with your doctor or health care provider about it?
Have you been prescribed medicine to make it stop?
Do you take anything to help with bowel movements? If so,
What do you take?
How often do you take it?
How long have you been taking it?
Have you discussed the need to take something to have a bowel movement with your doctor or health care provider?
Have you had any testing done on your bowels such as:
Have an enema using barium
Have you ever had a colonoscopy? If so,
When was it done?
What was the outcome?
Did your doctor or health care provider prescribe anything after your colonoscopy?
Have you ever been told you have hemorrhoids? If so,
What has been prescribed to treat them?
How often do they “bother” you?
Do you take any over-the-counter preparations for them?
Does your doctor or health care provider suggest that you have surgery to remove them? If so,
When was it done/when will it be done?
Have you ever been diagnosed or told that you have a problem with your liver? If so,
What have you been told?
How long have you been having problems with your liver?
Do you take any medicine for your liver problem?
Do you need to avoid anything because of your liver such as:
Did your skin ever have a yellow color? If so,
Is it yellow now?
If it was yellow in the past, how long did it last?
Did it ever turn yellow again?
Have you been told to avoid any foods because of your liver?
Have you ever been in the hospital because of a liver problem? If so,
Did you ever have to have fluid taken out of your belly because of your liver?
Did you ever have to have a tube in your nose because of bleeding caused by your liver?
Have you ever been told that you have a problem with your gallbladder? If so,
Were you told that you have stones?
Have you ever had bowel movements that looked like they didn’t have any color/were not brown? If so,
How long did that last?
What was done about it?
Do you ever have any pain that you have been told is caused by your gallbladder?
If you have had pain, was the pain:
Around your right shoulder blade on your back?
How long does the pain last?
What do you do for the pain? Do you:
Take over-the-counter medicine?
Avoid eating a certain type of food?
Have you had/are going to have surgery to remove your gallbladder?
When was/will it be done?
Are you experiencing any other problems after having your gallbladder removed?
Have you ever been told that you have a problem with your pancreas? If so, what is it?
Have you ever been in the hospital because of something being wrong with your pancreas? Have you ever been told that you had/have:
If you have been told that you have a pancreas problem, have you had to:
Change your diet?
What foods do you need to avoid?
Avoid all alcohol?
Have you ever been diagnosed with diabetes? (If so, you can either go into an in-depth assessment of the diagnosis of diabetes now or complete that assessment later. See a later chapter on more information about the assessment of a patient/client with diabetes.)
Do you take medicine such as enzymes for your pancreas? If so,
What are they?
How often do you have to take them?
Do you take them as prescribed?
The frequency of patients having bariatric surgery for obesity has been consistent. At times, a patient will be referred to telephonic care before/after the surgery to provide ongoing education and support. Should you have a patient who is recovering from bariatric surgery, the following assessment questions might be beneficial.
Would you happen to know your body mass index (BMI)? Or what is your current weight?
When are you scheduled for the surgery?
What type of surgery are you going to have?
What have you been told about the surgery?
Length of hospitalization?
Do you have any questions about what to expect after the surgery?
Have you talked with your doctor/health care provider about the questions after the surgery?
When did you have the procedure?
How are you feeling right now?
Have you been back to see the doctor after the surgery?
How successful has it been so far? Such as:
How much of a weight loss have you experienced?
Are you having any problems from the surgery?
How much food would you say you are currently able to eat?
Are there any foods that you are unable to eat?
When are you scheduled to see your doctor/health care provider again?
ALGORITHM FOR ASSESSING THE GASTROINTESTINAL SYSTEM
Similar to other body system assessments, this one is quite lengthy too. If you prefer, you can change the approach and just focus on problem areas. Questions to support this are as follows:
Assess for length of time nausea has been present.
Assess for possible causes such as:
Assess what has been done for the nausea such as:
Assess if vomiting is present. If so, assess what it looks like:
Green in color
Black like coffee grounds
Assess for abdominal pain with the nausea and vomiting.
Suspect gastrointestinal flu or food poisoning if associated with eating and encourage seeking medical attention.
Suspect gastrointestinal bleeding if emesis is red or black and coffee ground in appearance. (Emesis green in color is bile and not associated with any particular health problem.)
Suspect small bowel obstruction if nausea is unrelenting and associated with loud audible bowel sounds.
Encourage to seek immediate medical attention for emesis that is red or black coffee ground in appearance.
Assess for pain around the sternum or upper abdomen.
Assess for when the pain occurs: before eating, during, and after eating?
Assess what has been done to reduce the burning.
Assess if eating makes the burning worse or better.
Suspect gastritis if eating improves the burning.
Suspect duodenal ulceration if burning/pain occurs several hours after eating.
Encourage to seek medical attention for evaluation of the epigastric burning.
Assess for length of time diarrhea has been occurring: number of episodes, number of days.
Assess for any associated symptoms: gurgling, nausea, and vomiting.
Assess for color and consistency of stool.
Assess for presence of blood, mucus, or undigested food in the stool.
Suspect gastrointestinal infection for unexplained onset of diarrhea and encourage to seek medical attention.
Assess for last bowel movement.
Assess for routine bowel movement pattern.
Assess appearance of stool.
Assess for any leaking of stool or liquid stool. (Leaking of liquid stool could indicate an impaction.)
Assess for changes in diet, fluid intake, or activity to contribute to the development of constipation.
Assess if prescribed opioid analgesics. If so,
The name of the medication
Length of time taking the medication
Assess what has been done to self-treat the constipation and if it has been effective.
Assess for routine dietary intake, specifically for foods high in roughage.
Suspect bowel impaction if leaking of stool or brown-colored fluid is occurring.
Suspect constipation caused by diet/activity/fluids if a change in oral intake has occurred.
Suspect opioid-induced constipation if prescribed opioid analgesics.
Encourage to discuss constipation with doctor/health care provider before ongoing use of over-the-counter laxatives.
Assess for location of pain.
Right lower quadrant (suspect appendicitis)
Left lower quadrant (suspect diverticulitis/diverticulosis)
Mid-abdomen around umbilicus (suspect acute pancreatitis)
Assess for length of time pain has been occurring.
Assess for what makes the pain worse. What makes it better?
(If sitting up or bringing the knees to the abdomen makes the pain better, suspect acute pancreatitis and suggest to seek immediate medical attention.)
Assess for last bowel movement.
Assess for associated factors such as:
Upon having a bowel movement
Assess for abdomen feeling “bloated” or “swollen.”
Suspect acute abdomen, if right lower quadrant pain and suggest to seek immediate medical attention.
Suspect a flair of diverticulosis/diverticulitis if associated with eating certain foods and encourage to discuss the health problem with the doctor or health care professional.
Assess where the yellow color is most obvious: sclera of the eyes, palms of the hands, soles of the feet, and skin.
Assess how long the color has been present.
Assess if the skin is itchy or any other symptoms.
Assess for a change in the color of bowel movements.
Assess if associated with:
Suspect hepatitis if associated with nausea/vomiting, anorexia, fatigue, and fever and encourage to seek immediate medical attention.
Assess for when the bleeding started.
Assess if the bleeding is coating the bowel movement or present on toilet tissue.
Assess if the bleeding is associated with any abdominal or rectal pain.
Assess if diagnosed with hemorrhoids.
Assess how long the bleeding has been occurring.
Suspect colon pathology if bleeding nonpainful and encourage to seek immediate medical attention.
Suspect hemorrhoids if bleeding associated with burning/itching/throbbing pain and encourage to seek medical attention.
Right shoulder pain
Assess for approximate location of the pain.
Assess for length of time the pain has been occurring.
Assess for when the pain is most noticeable such as after ingesting a large meal with a high-fat content.
Assess what makes the pain better.
Assess for changes in bowel pattern or appearance of stool (suspect cholecystitis or cholelithiasis if stool is clay colored).
Suspect gallbladder disease and encourage to seek medical attention.
See Chapter 15 for additional information about gastrointestinal system disorders
TIPS FOR ASSESSING THE GASTROINTESTINAL SYSTEM
Remember that this is a body system that many people do not like to discuss. Emphasize that all information will be kept confidential.
Do not assume that older clients’ problems with this system are all age related. Normal age-related changes of the gastrointestinal system include change in smell and taste, slower gastric emptying, and slower propulsion of food through the small bowel and colon.
Ask if the client has made any dietary changes that could have caused the current issue.
Find out how much water/fluid is ingested every day. Oftentimes an older client may adjust oral fluid intake to prevent nighttime voiding. This could be a reason for a new onset of constipation.
Diligently assess if the client reports red or coffee-ground emesis or black stools. This could indicate an active or ongoing bleed somewhere throughout the gastrointestinal tract that needs to be thoroughly investigated.
Be sure to include asking if the client has any pain that might not seem to be related to the stomach or bowels such as shoulder pain caused by gallbladder disease.
When asking about weight, find out if the patient has had any changes (gains or losses) that would not be associated with oral intake. If a weight loss is reported, find out if it has been intentional. The patient/client may be following a restricted eating plan with the desired effect of weight loss.