Transcript Abdomen and Gastrointestinal System

Chapter 13
ABDOMEN AND
GASTROINTESTINAL SYSTEM
K E V I N DOBI , MS N , A P R N
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Anatomy and Physiology
• Abdominal cavity largest in body, containing:
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Stomach
Small and large intestines
Liver
Gallbladder
Pancreas
Spleen
Kidneys
Ureters
Bladder
Adrenal glands
Major vessels
In women: Uterus, fallopian tubes, ovaries
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Anatomy and Physiology
(contd.)
Esophagus lies outside abdominal cavity but is vital part of
gastrointestinal (GI) system.
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Anatomy and Physiology: Peritoneum,
Musculature, and Connective Tissue
Peritoneum, abdominal lining, is 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 and visceral
layers.
◦ Contains serous fluid that reduces friction between organs and membranes.
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Anatomy and Physiology: Peritoneum,
Musculature, and Connective Tissue
(contd.)
Rectus abdominis muscles form anterior border.
Vertebral column and lumbar muscles form posterior border.
Internal and external oblique muscles provide lateral support.
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Anatomy and Physiology: Peritoneum,
Musculature, and Connective Tissue
(contd.)
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 and Physiology:
Alimentary Tract
Alimentary tract extends from mouth to anus, 27 feet (8.2 meters) and
includes:
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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
Stomach is hollow, flask-shaped, muscular organ directly
below diaphragm in left upper quadrant.
Esophageal contents enter stomach through lower
esophageal sphincter and mix with digestive enzymes and
hydrochloric acid.
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Anatomy and Physiology:
Stomach (contd.)
Gastric acid continues breakdown of carbohydrates that
begin in mouth.
◦ Pepsin breaks down proteins to peptones and amino acids.
◦ Gastric lipase acts on emulsified fats—triglycerides to fatty acids or glycerol.
◦ Liquefies food into chyme and 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 and 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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Anatomy and Physiology:
Large Intestine (Colon) and Rectum
Large intestine is 5 feet long and consists of cecum, appendix,
colon, rectum, and anal canal.
◦ Ileal contents empty into cecum via ileocecal valve.
◦ Appendix extends from base of cecum.
Colon is divided into three parts: ascending, transverse, and
descending.
◦ End of descending colon turns medially and inferiorly to form S-shaped sigmoid
colon.
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Anatomy and Physiology: Large
Intestine (Colon) and Rectum (contd.)
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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Anatomy and Physiology:
Accessory Organs
Accessory organs of GI tract:
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Salivary glands
Liver
Gallbladder
Pancreas
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Anatomy and Physiology:
Accessory Organs: 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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Anatomy and Physiology:
Accessory Organs: Liver (contd.)
Liver functions:
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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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Anatomy and Physiology:
Accessory Organs: 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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Anatomy and Physiology:
Accessory Organs: 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, and 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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Anatomy and Physiology:
Accessory Organs: 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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Anatomy and Physiology:
Accessory Organs: Spleen (contd.)
Functions of spleen:
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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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Anatomy and Physiology:
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.
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Anatomy and Physiology:
Urinary Tract – Kidney Function
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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Anatomy and Physiology:
Urinary Tract – Ureters
Ureters:
◦ Urine forms in nephron, flows from distal tubes and collecting ducts into
ureters and into bladder.
◦ Composed of long, intertwining muscle bundles extending 12 inches to
insertion at base of bladder.
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Anatomy and Physiology:
Urinary Tract – 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.
◦ * Nurses check for at no more than 30 cc residual urine after foley removal
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Anatomy and Physiology:
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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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 your drink alcohol?
◦ How much?
◦ How often?
Do you smoke?
◦ 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?
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Problem-Based History:
Abdominal Pain (contd.)
Pain associated with other symptoms?
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Stress?
Fatigue?
Nausea and vomiting?
Gas?
Constipation or diarrhea?
Women: Associated with menstrual period?
◦ Last menstrual period?
◦ Could you be pregnant?
ALWAYS, ALWAYS, ALWAYS!!!
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Problem-Based History:
Nausea and Vomiting
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:
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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:
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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?
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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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EXAMINATION
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Examination: Procedures and
Techniques with Normal Findings
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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Examination: Procedures and
Techniques with Normal Findings –
Auscultation
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.
◦ Inspect
◦ Auscultate
◦ Palpate
◦ Percuss
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Examination: Procedures and
Techniques with Normal Findings –
Palpation
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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Examination: Special Circumstances
or Advanced Practice
Percuss all quadrants of abdomen using indirect percussion
to assess density of abdominal contents.
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).
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Examination: Special Circumstances or
Advanced Practice (contd.)
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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Examination: Special Circumstances or
Advanced Practice (contd.)
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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Examination: Special Circumstances or
Advanced Practice (contd.)
Assess abdomen for fluid, if fluid is suspected.
Assess abdominal pain due to inflammation.
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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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Examination: Special Circumstances or
Advanced Practice (contd.)
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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Common Problems and
Conditions:
Alimentary Tract – 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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Common Problems and
Conditions:
Alimentary Tract – 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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Common Problems and Conditions:
Alimentary Tract – 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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Common Problems and
Conditions:
Alimentary Tract – 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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Conditions:
Alimentary Tract – 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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Common Problems and
Conditions:
Alimentary Tract – 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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Common Problems and Conditions:
Hepatobiliary System – 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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Common Problems and Conditions:
Hepatobiliary System – 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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Common Problems and Conditions:
Hepatobiliary System – 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.
◦ * What type of pain is this called?
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Common Problems and Conditions:
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.
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Common Problems and Conditions:
Pancreas – Pancreatitis (contd.)
Clinical findings:
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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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Common Problems and
Conditions:
Urinary System – UTI
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.
Other causes?
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Common Problems and
Conditions:
Urinary System – UTI (contd.)
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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Common Problems and
Conditions:
Urinary System – 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:
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.
D. Ask the patient to straighten his legs for the abdominal
exam.
A.
B.
C.
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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.
2.
3.
What risk factors does Sylvan have for GERD?
What measures might have helped prevent GERD?
What should the nurse do in this clinical situation? Prioritize actions.
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THE END
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