Transcript Cultural Diversity

Health Alterations II
Management of Clients
with Problems of the
Gastrointestinal System
Lecture 1.
Asessment of the
Gastrointestinal, Biliary, and
Exocrine Pancreatic Systems
The gastrointestinal (GI) system, also termed the
digestive system and alimentary canal, consists
of the GI tract and its accessory organs.
Its primary function is to convert ingested
nutrients and fluids into a form that can be used
by the cells of the body. This goal is
accomplished through the processes of ingestion,
digestion, and absorption.
The second major function of the GI system is
the storage and final excretion of the solid waste
products of digestion. Proper functioning of the
GI system is essential to the maintenance of
proper nutrition and health
ANATOMY AND PHYSIOLOGY
The upper portion of the GI
tract consists of those
structures that aid in the
ingestion and digestion of
food. These structures
include the mouth,
esophagus, stomach, and
duodenum, plus the related
organs of the biliary system
and exocrine pancreas. The
lower GI tract consists of the
small and large intestines,
the rectum, and the anus.
The GI system is primarily composed of a hollow,
muscular tube approximately 9 m (30 feet) long that
stretches from the mouth to the anus.
Although this muscular tube is located within the
body, it is actually an extension of the external
environment. The walls of the GI tract successfully
prevent most harmful agents from entering the body
and essential body fluids and materials from leaving
the body. The composition of the walls is
predominantly smooth muscle; however, the mouth
and upper esophagus, along with a portion of the
rectum and anus, consist of voluntary muscle.
I. Mouth
The mouth is made up of the lips, cheeks, tongue,
hard and soft palates, teeth, and salivary glands.
These structures begin the digestive process by
mechanically breaking down and lubricating the
food. Because digestive enzymes can function only
on the exposed surfaces of food particles, the teeth
must begin the breakdown of food. No other portion
of the GI system can perform the function of the
teeth in their absence.
The lubrication of food is accomplished by the action
of the watery and mucous secretions of the salivary,
parotid, sublingual, and submandibular glands of the
mouth. Saliva also contains ptyalin (amylase), which
hydrolyzes starch to maltose. Small amounts of
saliva, which contain immunoglobulin A (IgA)
antibodies to many normal environmental
microorganisms, are produced continually to keep
the tissues of the mouth moist and clean. After
chewing and moistening are completed, the
muscular tongue pushes the food bolus back to the
pharynx to initiate swallowing (deglutition).
II. Esophagus
The esophagus begins at the lower end of the pharynx. It is a hollow, muscular
tube 10 inches (25 cm) in length that lies behind the trachea, passes through
the thorax, and connects the mouth and stomach. The upper third is composed
of skeletal muscle, and the lower two thirds are smooth muscle. Both ends of
the esophagus are protected by sphincters that help prevent the reflux of gastric
contents. Both sphincters are normally closed, except during the act of
swallowing.
The primary function of the esophagus is to move the food bolus by peristalsis
from the pharynx to the stomach. No enzymes are secreted by the esophagus,
and only mechanical digestion takes place. The secretion of mucus assists in the
movement of the food bolus and protects the walls of the esophagus from
abrasion by partially digested food.
Swallowing is a complex physiologic mechanism that must be accomplished
without compromising respiration. It consists of three phases: (1) the voluntary
phase, in which the tongue forces the bolus of food into the pharynx; (2) the
involuntary pharyngeal phase, in which the food moves into the upper
esophagus; and (3) the esophageal phase, during which food moves down into
the stomach. The esophageal muscles are activated by the glossopharyngeal
and vagal nerves, which create rhythmic peristaltic waves that propel the food
toward the stomach. Food is prevented from passing into the trachea by the
closing of the epiglottis and the opening of the esophagus.
III. Stomach
The stomach is roughly J shaped and lies in the upper abdomen to the left of midline. It is
positioned to the left of the liver, to the right of the spleen, and posterior to both organs.
It is a muscular pouch whose shape changes with its contents. Its three major regions are
the fundus, body, and antrum. The cardiac sphincter protects the opening from the
esophagus, and the pyloric sphincter protects the exit to the duodenum. The rugae, or
longitudinal folds, of the stomach enable it to quadruple in size and increase from a
resting volume of 50 ml to a capacity of approximately 1500 ml for food digestion without
major changes in pressure. The stomach has an outer serous layer and three layers of
smooth muscle. The outermost layer of smooth muscle is longitudinal, the middle layer is
circular, and the inner layer is oblique. The rugae are found on the inner mucosal layer.
The stomach primarily serves as a reservoir but also has
digestive and secretory functions. Food is stored in the
stomach until partially digested. The fundus contains chief
cells, which secrete digestive enzymes, and parietal cells,
which secrete water, hydrochloric acid (HCL), and the
intrinsic factor that is essential for the absorption of vitamin
B12. The HCL is responsible for the highly acidic medium of
the stomach (pH of 0.9 to 1.5), which is needed to activate
the enzymes that initiate protein digestion. This highly acidic
pH also serves as a protective barrier, destroying most
ingested microorganisms. Gastric acid secretion is under the
control of parasympathetic stimulation via the vagus, as is
the secretion of gastrin and histamine. Gastrin is a hormone
secreted from endocrine cells in the gastric glands of the
stomach in response to vagal stimulation and mechanical
distention of the stomach. The secretion of histamine 2 (H2)
also increases gastric acid secretion. Approximately 2 to 2.5 l
of gastric secretions are produced each day.
The gastric mucosa is covered by a thick mucous gel layer
produced by the densely packed epithelial cells of the mucosa. The
mucous layer is almost completely impermeable to hydrogen ions.
The mucosal epithelial cells also secrete bicarbonate, which acts as
a buffer and helps neutralize the acidic secretions. The combined
actions of these two mechanisms are so effective that, although
the gastric secretions have a pH of less than 2.0, the intraluminal
pH of the mucosa is maintained at about 7.0.
Gastric emptying is controlled by both hormonal and autonomic
nervous system activity. Parasympathetic stimulation, by the vagus
nerve increases both peristalsis and secretion. Sympathetic
stimulation inhibits them. The peristaltic contractions of the
stomach propel the chyme toward the antrum and occur at a
frequency of about three to five contractions per minute. The
pylorus closes during antral contraction, and larger food particles
are propelled back toward the body of the stomach for further
mixing. Gastric contents are emptied into the duodenum between
peristaltic contractions. Although the pylorus is not a true anatomic
sphincter, it does help prevent the backflow of duodenal contents
and bile salts into the stomach.
IV. Gallbladder and Biliary Ductal System
The gallbladder is a pear-shaped organ that lies on the inferior surface of
the liver. It is composed of serous, muscular, and mucus layers and has a
usual capacity of 50 ml, although it can increase in size under normal
conditions. Innervation of the gallbladder is from the parasympathetic
and sympathetic nervous system. The cystic duct connects the
gallbladder with the remaining structures of the ductal system — the
hepatic ducts and common bile duct.
The major function of the gallbladder is to store and concentrate bile.
Bile, which is formed in the liver, is excreted into the hepatic ducts, which
unite to form the common bile duct. It passes behind the pancreas, is
joined by the pancreatic duct, and empties into the duodenum. The
sphincter of Oddi regulates the flow of bile into the duodenum. A second
sphincter is located above the junction with the pancreatic duct and
controls the flow of bile in the common bile duct. When this sphincter is
closed, bile moves back into the gallbladder, where it is concentrated
fivefold to tenfold. Because bile can be released directly into the
duodenum from the liver, the gallbladder is not essential to life. Bile salts
facilitate fat digestion by emulsifying fats for action by intestinal lipases
and facilitate the absorption of fats, fat-soluble vitamins, and cholesterol.
The release of bile from the gallbladder or liver is controlled by
cholecystokinin (CCK). Approximately 600 to 800 ml of bile is
produced daily. CCK is released from the walls of the duodenal
intestinal mucosa when lipids, amino acids, and hydrogen ions
enter the duodenum from the stomach. It travels via the blood
to the gallbladder and causes contraction of the gallbladder's
smooth musculature and relaxation of the sphincter at the end
of the common bile duct (the sphincter of Oddi), so that bile can
be emptied into the duodenum.
Most of the bile salts are reabsorbed from the intestine into the
enterohepatic circulation and returned to the liver, where they
can be recirculated. The system is so efficient that only 15% to
25% of the bile salt pool needs to be replaced by the liver each
day.
V. Pancreas
The pancreas is an elongated,
flattened organ located in the
posterior abdomen, with its
head lying within the curve of
the duodenum and its tail
resting against the spleen. The
pancreas has both exocrine and
endocrine functions. The
exocrine functions are carried
out by the acini cells and duct
system, and the endocrine
functions are carried out by
islets of Langerhans cells.
The pancreas is divided into three parts, which are composed of
lobules. The lobules are formed from groups of secretory cells termed
acini, which drain into a ductal system that ultimately reaches the
main pancreatic duct of Wirsung. This major duct extends the entire
length of the gland. At the head of the pancreas the ductal secretions
enter the duodenum through the ampulla of Vater. The sphincter of
Oddi controls its opening.
Approximately 2 l of pancreatic secretions are produced daily. The
ductal epithelium produces a balanced electrolyte secretion, and the
acini secrete digestive enzymes in an inactive precursor state. The
pancreatic secretions contain trypsin, a proteolytic enzyme, which
breaks down protein; pancreatic amylase, which breaks down starch;
and lipase, which hydrolyzes fat into glycerol and fatty acids. The
pancreatic acini also produce an enzyme inhibitor that prevents the
activation of the secretions before they reach the duodenum. The
production of the pancreatic secretions is controlled by the action of
the parasympathetic nervous system, gastrin, and hormones released
from the duodenum during digestion.
VI. Intestines
The small intestine is about 2.5 cm (1 inch) wide and 6 m (20 feet)
long and fills most of the abdomen. It consists of three parts: (1)
the duodenum that connects to the stomach, (2) the jejunum, or
middle portion, and (3) the ileum that connects to the large
intestine (see Figure 31-1).
The large intestine is about 6 cm (2.5 inches) wide and 1.5 m (5
feet) long. It also consists of three parts: (1) the cecum that
connects to the small intestine, (2) the colon, and (3) the rectum.
The ileocecal valve prevents backward flow of fecal contents from
the large intestine to the small intestine. The vermiform appendix,
which has no known function, is an appendage close to the
ileocecal valve. The colon is subdivided into four sections: the
ascending, transverse, descending, and sigmoid colons. The points
at which the colon changes direction are named for adjacent
organs: the liver (hepatic flexure) and the spleen (splenic flexure).
The rectum is 17 to 20 cm (7 to 8 inches) long, ending in the 2- to
3-cm anal canal. The opening of the anus is controlled by a smooth
muscle internal sphincter and a striated muscle external sphincter.
VI.I. Small Intestine
The primary functions of the small intestine are the digestion of food and the absorption
of nutrients. This process occurs primarily in the jejunum and ileum. The duodenum
contains the opening for the bile and pancreatic ducts, which allow bile and pancreatic
secretions to enter the intestine. Mucus-producing glands are concentrated where gastric
contents are emptied and digestive secretions enter the duodenum. The mucus helps
protect the duodenum from the acids in the gastric chyme and the actions of the
digestive enzymes.
Digestion begins in the mouth and stomach, but it takes place primarily in the small
intestine. The intestinal mucosa is impermeable to most large molecules, so proteins,
fats, and complex carbohydrates must be broken down into small particles before they
can be absorbed. The intestinal mucosa also secretes surface enzymes that aid in
digestion and about 2 l/day of serous fluid that acts as a diluting agent to facilitate
absorption.
Carbohydrate digestion, which begins in the mouth, is completed in the small intestine as
disaccharides are broken down into monosaccharides (glucose, fructose, and galactose)
by the action of intestinal enzymes and pancreatic amylase. Protein digestion, which
begins in the stomach, is completed as polypeptides are broken down into peptides and
amino acids by the action of pancreatic trypsin. Fat digestion is accomplished by
emulsification into small droplets by the action of bile and pancreatic lipase. The droplets
are then further broken down into glycerol and fatty acids. The release of digestive
secretions is stimulated by the hormones secretin and CCK (also called pancreozymin),
as well as by the action of the parasympathetic nervous system.
The inner mucosal surface of the
small intestine is covered with
millions of villi, which are the
functional units for absorption. Each
villus is equipped with a blind-end
lymph vessel (lacteal) in its center,
which is surrounded by capillaries,
venules, and arterioles. These
structures bring blood to the surface
of the intestine and provide a
network for absorption into the
portal blood or lymphatic system.
Ninety percent of absorption occurs
within the small intestine by either
active transport or diffusion. Active
transport requires a metabolic
energy expenditure and is used to
absorb amino acids,
monosaccharides, sodium, and
calcium. Fatty acids and water
diffuse passively, primarily into the
lymphatics.
The contents of the small intestine (chyme) are propelled
toward the anus by regular peristaltic movements. Both
segmental and propulsive movements occur. The segmental
movements involve primarily the circular muscles of the
intestine. Slow contractions move the chyme back and forth in
small segments of the intestine (1 to 4 cm). This movement
mixes the chyme and facilitates digestion and absorption.
Segmental peristaltic movements increase after meals. The
propulsive peristaltic movements involve intestinal segments 10
to 20 cm long. Contraction occurs in the proximal segment, with
relaxation in the distal segment. Chyme advances slowly and
normally takes 3 to 10 hours to move from the stomach to the
colon. Parasympathetic stimulation, primarily through branches
of the vagus nerve, increases peristaltic activity. Sympathetic
stimulation is primarily inhibitory.
VI.II. Large Intestine
Minimal chemical digestion takes place in the large intestine. It functions primarily to
absorb water and electrolytes from the chyme and store the food waste (feces) until
defecation. Reabsorption occurs predominantly in the right or ascending colon. The
colon can absorb six to eight times more fluid than is delivered to it daily, and only
approximately 100 ml of fluid is left in the colon to be mixed with the fecal residue.
The large number of microorganisms found in the large intestine further break down
the residual proteins that were not digested or absorbed in the small intestine. The
breakdown of amino acids produces ammonia, which is converted to urea by the liver.
These intestinal bacteria also play a vital role in the synthesis of vitamin K and some of
the B vitamins. The only significant secretion of the colon is mucus, which protects the
walls and helps the fecal matter adhere into a mass.
Approximately 450 ml of chyme reaches the cecum each day. The transit time in the
large bowel is slow, taking about 12 hours to reach the rectum. The fecal contents in
the colon are pushed forward by mass movements that occur only a few times each
day. These mass movements are stimulated by gastrocolic reflexes initiated when food
enters the duodenum from the stomach, especially after the first meal of the day.
The rectum is well innervated with sensory fibers. Parasympathetic fibers are
responsible for the contraction of the rectum and relaxation of the internal sphincter of
the anus. The defecation reflex occurs when feces enter the rectum. Afferent impulses
are transmitted to the sacral segments of the spinal cord; subsequently, reflex impulses
are transmitted back to the sigmoid and rectum, initiating relaxation of the internal
anal sphincter.
VII. Physiologic Changes With Aging
Gastrointestinal complaints are extremely common in elderly persons. Distinct
changes occur in the GI system with aging, although these changes are
incompletely understood. Although most of the aging-related changes do not
interfere with normal functioning, it is important for nurses to be cognizant of
the changes and incorporate appropriate modifications when planning care for
elders. In addition, the GI effects of other chronic illnesses such as diabetes
require careful consideration because they are usually more important than the
effects of aging itself.
In the mouth, teeth darken and may loosen or fracture, and the gums recede.
Salivary gland output decreases, which causes mouth dryness and increased
susceptibility to infection and tissue breakdown. Aging causes decreased motility
and strength of peristalsis in the esophagus, but these changes appear to have
minimal significance in healthy persons. Some deterioration in the lower
esophageal sphincter may increase the frequency of esophageal reflux.
Gastric motility and emptying diminish slightly but progressively with age, and
gastric acid secretion also decreases steadily after age 50. Achlorhydria
(absence of free HC1) is relatively common. These changes can produce minor
problems in digestion but are usually asymptomatic. Chronic gastritis is common
in elderly persons, but the condition is usually the result of bacterial colonization
by Helicobacter pylori and not aging.
No significant changes in biliary system morphology are associated with aging.
However, the composition of the bile becomes increasingly lithogenic (likely to
produce calculi), possibly related to an increase in biliary cholesterol; therefore
the incidence of gallstones increases with each decade.
The pancreas exhibits ductal hyperplasia and fibrosis with aging, but these
changes are not necessarily associated with altered functioning. The output of
pancreatic secretions steadily declines after age 40, but related problems with
absorption have not been documented.
Age-related changes in small intestinal function are important and can lead to
poor nutrition even with adequate intake. Nutrient absorption is impaired,
particularly the absorption of carbohydrates. Absorption of water-soluble
vitamins remains intact, but the absorption of vitamin D is defective in many
elderly persons, and the active transport of calcium is also impaired.
Decreased production of secretory IgA can lead to an increase in the frequency
and severity of infections.
Chronic constipation is one of the most common complaints in elderly persons.
Yet the segmental mass movements and contractions of the large intestine
have been found to be unchanged as long as the individual remains physically
active. The incidence of both diverticula and polyps in the colon increases with
age. There is a decrease in elasticity in the rectum and a steady decrease in
the rectal volume, which can result in sphincter failure. However, the sensation
of rectal fullness remains intact, and most problems with bowel incontinence in
elderly persons are not attributable to the effects of aging.
HEALTH HISTORY
A thorough health history is necessary
to adequately assess the health status
of persons with potential dysfunction of
the GI system.
I. Patient/Family History
The nurse asks the patient about previous GI
problems, hospitalizations, and surgeries.
This includes past and current medication
use, both over-the-counter and prescribed.
The use of antacids and laxatives is
particularly important. The nurse inquires
about the presence of GI problems in the
nuclear or extended family, including cancer
and disorders such as inflammatory bowel
disease, which have a documented hereditary
link.
II. Diet and Nutrition
The adequacy of the diet, in terms of both quality and quantity, can be quickly estimated
through comparison of the diet with recommended food intake patterns. Nutritional
assessment has particular significance in GI disorders, because it may reveal changes in
eating patterns characteristic of specific illnesses or disorders. The nutritional assessment
includes an exploration of usual eating patterns and any changes that may be the result
of illness or specific symptoms. The assessment explores changes in appetite, food
preferences and intolerances, food allergies, planned and unplanned changes in weight,
adherence to special or therapeutic diets, and the use of dietary or vitamin supplements.
A 24-hour dietary recall may be a useful tool to approximate caloric and specific nutrient
intake and analyze the overall adequacy of the diet. Symptoms related to food intake
should also be carefully assessed. Changes in appetite and the presence of such
symptoms as dysphagia, nausea, and discomfort are carefully explored.
Lifestyle, economic, and cultural factors affecting nutrition are also assessed. Food has
multiple social and emotional values for individuals that are distinct from its role in
nutrition. Financial resources, access to food preparation and storage facilities, and
religious or social beliefs may all influence both the quality and quantity of the diet.
Lifestyle factors can have a direct or indirect effect on GI function. Gastrointestinal
symptoms commonly develop or worsen in response to life stressors. Open-ended
questions are most effective for exploring beliefs and feelings about food.
A complete nutritional assessment includes an evaluation of the patient's use of sugar
and salt substitutes, coffee, alcohol, and tobacco (both chewing and smoking). The
presence of dentures is an essential consideration because dentures may significantly
influence food selection and chewing.
III. Abdominal Pain
Although pain is not an early or common manifestation of GI
disease, it is frequently the reason individuals seek medical
attention. The nurse assesses its onset, duration, character,
location, and relationship to meals, stressful events, activity, or
medications. The patient is asked to point to the site of pain in
the abdomen. Pain may be experienced anywhere along the
length of the GI tract in a specific localized pattern, a general
nonspecific pattern, or referred to another somatic or skeletal
region that shares the same nerve innervation. Abdominal pain
may be continuous, episodic, or associated with eating. The
pain sensation is thought to arise from the distention or sudden
contraction of a hollow viscus; therefore, local stretching or
traction on pain-sensitive structures will elicit the pain stimulus.
The painful area may exhibit local muscle guarding, which
serves as a protective mechanism. The pain associated with
pancreatic or biliary dysfunction is usually severe.
Common Sites of Reffered Pain
IV. Food Intolerance
Abdominal pain or discomfort may also be reported
as heartburn, indigestion, belching, or bloating and
requires further clarification. The discomfort may
interfere with chewing or swallowing food. Specific
foods, such as those that are spicy, very hot, or very
cold, may precipitate the discomfort; smoking and/or
alcohol consumption may also trigger abdominal
discomfort. The patient may have already self-treated
the abdominal pain with a variety of over-the-counter
preparations such as antacids and H2 receptor
antagonists. Difficulties in swallowing (dysphagia)
can also result in abdominal discomfort.
V. Nausea and Vomiting
Nausea and vomiting are commonly associated with
GI problems, and the nurse assesses for onset,
frequency, duration, patterns of occurrence,
relationship to meals, and the quantity and character
of the emesis. Nausea and vomiting are commonly
associated with medication administration. Emesis
may contain red blood indicative of recent bleeding.
"Coffee-ground" emesis may indicate old bleeding in
the stomach. The presence of bile produces a green
color and has a bitter taste; brown vomitus may
contain fecal matter.
VI. Fatigue and Weakness
Persons with GI system problems often complain of
fatigue or weakness. Inadequate nutrient intake,
abnormal fluid and electrolyte status, and increased
metabolic demands may all contribute to the problem. It is
important for the nurse to carefully consider other
problems that may be contributing to the symptoms,
including cardiac, respiratory, renal, and other metabolic
disorders. These complaints may be present in a wide
variety of situations, but their careful assessment is
essential for planning an overall approach to care.
Resolution of these problems usually takes time. Fatigue
and weakness may also contribute to weight loss,
particularly when associated with persistent anorexia,
nausea, vomiting, or abdominal pain.
VII. Elimination Patterns
Patterns of bowel elimination vary significantly among healthy individuals, and these
patterns are commonly altered by GI system disorders. The nurse assesses the
individual's usual elimination pattern and explores any changes that have occurred. The
use of laxatives, suppositories, or other products to support bowel elimination is carefully
assessed.
Changes in the normal pattern of bowel elimination may represent a physiologic
alteration, a pathologic condition, or simply a change in normal diet and activity
patterns. Constipation, defined as the presence of small, hard stools that are passed with
difficulty at infrequent intervals, is a classic example. Constipation may be a temporary
response to a change in diet or activity, or it may be a sign of bowel obstruction.
Constipation may also result from the administration of opioids that slow peristalsis,
whereas diarrhea can be the result of surgical interventions that remove significant
bowel segments. Diarrhea and stools containing mucus, pus, and possibly undigested
food may indicate enteritis or invasion by a parasite. Obstruction in the descending colon
may produce small, ribbon-shaped stools, or no stool if the obstruction is complete.
When fat absorption is abnormal, steatorrhea (bulky, foul-smelling, fatty stools) may
occur. If biliary obstruction is present, the patient may give a history of clay-colored
(grayish) stools. Bright red blood in the stool indicates lower GI bleeding. Blood from the
upper GI tract is broken down by digestive secretions, and the stool appears black and
sticky (tarry). Sometimes the presence of blood in the GI tract acts as a powerful
cathartic and may produce abrupt, severe diarrhea. Blood in the stool (melena) may be a
recent or a chronic symptom and may result from erosion of the mucosa, leading to
perforation of the muscle wall or rupture of a blood vessel. All cases of melena and/or
rectal bleeding should be immediately explored since both are symptoms associated with
colorectal cancer.
PHYSICAL EXAMINATION
Information gained from the physical
examination helps the nurse determine
the patient's baseline status and
develop an appropriate plan of care.
I. Mouth
Assessment of the mouth provides data about the patient's ability to salivate,
masticate, and swallow. The lips are observed for symmetry, color, moisture, swelling,
cracks, or lesions. If asymmetry is noted, the ability to masticate and swallow is
assessed. A tongue blade and penlight are needed to improve visualization, and gloves
should be worn for all examinations of the mouth. In certain situations, a mask and
eye shield may also be appropriate.
The lips are normally reddish in color and are good indicators of pallor or cyanosis.
Dryness may indicate dehydration, and cracks or fissures can occur with excessive
dryness, exposure to cold, poorly fitting dentures, or a riboflavin deficiency. When
cracks occur in the corners of the mouth they are referred to as angular stomatitis.
Swelling of the lips is usually the result of an inflammatory response. Lesions on the
lips may be benign or malignant. A commonly encountered benign lesion is herpes
simplex (cold sore, fever blister), which is caused by a virus and can create enough
discomfort to limit mastication.
The enamel surface of the teeth should be white but will darken with surface stains
(tea, coffee, tobacco). Commonly found abnormalities of the teeth include caries, loose
or broken teeth, and absence of some or all teeth. The gums or gingivae are normally
pink, attach to the teeth, and fill the interdental surfaces. Recession of the gum line is
not uncommon in older individuals. If the person is partially or completely edentulous
(without teeth), the gingivae are examined for areas of redness caused by improperly
fitting dentures, partial plates, or implants. The person is then asked to insert the
dentures so their correct fit and comfort for chewing can be assessed.
The buccal mucosa is light pink, although patchy pigmentation is seen in dark-skinned
individuals. The mucosa is examined for moisture, white spots or patches, debris, areas
of bleeding, or ulcers resulting from ill-fitting dentures or braces. Dryness and debris
may indicate dehydration. White, curdy patches, which are removable with some effort,
may be caused by candidiasis (thrush). White, nonremovable patches (leukoplakia);
white plaques within red patches; or red, granular patches (erythroplakia) may be
premalignant lesions and should be reported to the physician. A round or oval white
ulcer surrounded by an area of redness is indicative of an aphthous ulcer (canker sore).
While the tongue is depressed with a tongue blade and the person says "Ah," the soft
palate is observed for symmetry and the effective functioning of cranial nerve X, the
vagus, which is necessary for effective swallowing. The uvula, soft palate, tonsils, and
posterior pharynx are observed for signs of inflammation. Tongue mobility and function
are essential to mastication, taste, and swallowing. Normally there is no limitation to
movement in any direction, but the tongue deviates toward the paralyzed side with
paralysis of the twelfth cranial nerve (hypoglossal). A thin, white coating and presence of
large papillae on the dorsum of the tongue are normal findings. A thick coating indicates
poor oral hygiene; and a smooth, red surface suggests a nutritional deficiency. The
ventral surface is examined for leukoplakia, ulceration, or nodules, any of which may
indicate malignancy.
Any distinctive odor of the breath is noted. A foul odor may occur after the ingestion of
certain foods, with poor hygiene or oral infections, and with some metabolic dysfunctions
such as diabetic ketoacidosis, liver disease, and bowel obstruction. Normally the
mandible slides forward and down without difficulty, and a "cracking" sound is audible
when the mouth is opened widely. The interior of the mouth is also carefully examined
with a gloved finger to check for areas of tenderness, ulcers, and lumps.
II. Abdomen
Examination of the abdomen determines the presence or
absence of (1) tenderness, (2) organ enlargement, (3) masses,
(4) spasm or rigidity of the abdominal muscles, and (5) fluid or
air in the abdominal cavity. Physical examination of the
abdomen is performed in the following order: inspection,
auscultation, percussion, and palpation. Auscultation is
performed before percussion and palpation, because the latter
two may alter the frequency and intensity of bowel sounds.
The surface of the abdomen can be divided anatomically into
either four quadrants or nine regions. The patient is placed in a
supine position and kept as relaxed as possible. Bending the
patient's knees slightly, placing a small pillow under the head,
and positioning the patient's arms flat on the bed can help the
patient to relax the abdominal muscles and make palpation
easier. Good lighting should be available.
II.I. Inspection
Finding
Interpretation
Scars or striae
May be result of pregnancy, obesity, ascites, tumors, edema, surgical
procedures, or healed burned areas
Engorged veins
May be caused by obstruction of vena cava or portal vein and circulation from
abdomen
Skin color variation
May be caused by jaundice (yellow), inflammation (red), or intraabdominal
hemorrhage (blue)
Visible peristalsis
May be caused by pyloric or intestinal obstruction; normally peristalsis not
visible except for slow waves in thin persons
Visible pulsations
Normally slight pulsation of aorta, visible in epigastric region
Visible masses and
altered contour
Observe for hernias, distention of ascites, and obesity; instructing patient to
cough may bring out hernia "bulge" or elicit pain or discomfort in the
abdomen; marked concavity may be caused by malnutrition
Spider angioma
Appear on upper part of body and blanch with pressure; commonly result
from liver disease
III. Auscultation
Finding
Interpretation
Absence of bowel sounds in 5
minutes
Peritonitis, paralytic ileus, and hypokalemia
Repeated, high-pitched bowel
sounds occurring at frequent
intervals
Increased peristalsis caused by gastroenteritis, early
pyloric obstruction, early intestinal obstruction, or
diarrhea
Bruit
Presence of abnormal sound caused by turbulence of
blood flow through partially occluded or diseased aorta
or renal artery
Hum and friction rub
Heard over liver and splenic areas, indicating an
increased venous blood flow, possibly related to
peritoneal inflammation
IV. Percussion
Percussion of the abdomen is used primarily to confirm the size of
various organs and to determine the presence of excessive
amounts of fluid or air. Normally, percussion over the abdomen is
tympanic because of the presence of a small amount of swallowed
air within the GI tract. A dull or flat percussion note is found over a
solid structure. Dull sounds normally occur over the liver and
spleen or a bladder filled with urine. Abnormal percussion findings
occur because of the presence of ascites or abnormal masses.
Ascites classically produces a shifting dullness, which is caused by
fluid movement to dependent areas. Interpreting the sounds of
abdominal percussion may be difficult in obese individuals.
The four quadrants are percussed beginning with the thorax and
moving downward systematically. The degree of tympany, from soft
to pronounced, is recorded. Tympanic sounds should be heard
beginning at the ninth interspace in the left upper quadrant of the
abdomen.
V. Palpation
Palpation is of value in determining the outlines of abdominal organs, the presence and
characteristics of any abdominal masses, and the presence of direct tenderness,
guarding, rebound tenderness, and muscular rigidity. In the presence of gallbladder
disease, normal palpation of the liver elicits sharp pain and a positive inspiratory arrest
(Murphy's sign). The acute onset of pain causes the patient to stop inspiration abruptly,
midway through the breath.
Abnormal findings from palpation may include (1) direct tenderness over an organ
capsule, (2) rebound tenderness, (3) muscular rigidity, or (4) masses that may be felt if
they are large enough or close enough to the surface. Distinction should be made
between a distended abdomen that is firm to the touch and one that is soft to the touch.
Light palpation is used to elicit tenderness and cutaneous hypersensitivity. The nurse
uses the pads of the fingertips, with the fingers together, and presses gently, depressing
the abdominal wall about 1 cm. All quadrants are palpated using smooth movements.
Deep palpation is used to delineate organs and masses and should be performed only by
properly trained persons because improper technique can result in injury. The nurse
again uses the palmar surface of the fingers but presses more deeply using a single- or
two-handed technique. Known tender or painful areas should be assessed last. Rebound
tenderness is tested by pressing slowly but firmly over the painful site. The fingers are
then quickly withdrawn. Acute pain on withdrawal reflects peritoneal inflammation
(positive Blumberg's sign). This maneuver can be extremely painful and should never be
performed unnecessarily.
VI. Rectum
The normal perineal and perianal skin
resembles the skin on the rest of the
body with no breaks in integrity.
Abnormal findings may include pruritus
ani, coccygeal or pilonidal sinus tract
openings, fistulas, fissures, external
hemorrhoids, or rectal prolapse.
Internal hemorrhoids may appear when
the patient bears down
DIAGNOSTIC TESTS
Laboratory tests
Stool Examination
Radiologic Tests (Rx, Ultrasound,
Computer Tomography, Radionuclide
Imaging, Cholecystography,
Cholangiography)
Special Tests
Esophageal Function Tests (Manometry, pH
Monitoring, Esophageal Clearance Test, Acid
Perfusion Test (Bernstein Test))
Tests of Gastric Function (Gastric Analysis (Basal
Gastric Secretion and Gastric Acid Stimulation Tests),
Tubeless Gastric Analysis (Diagnex Blue Test),
Schilling Test (vitamin B12 absorption), Urea Breath
Test)
Biopsy (Upper Gastrointestinal Biopsy, Intestinal
Biopsy Intestinal Biopsy)
Endoscopy (Esophagogastroduodenoscopy,
Endoscopic Retrograde Cholangiopancreatography,
Colonoscopy)