Assessment of the Gastrointestinal System

 

Assessment of the Gastrointestinal System

Objectives

After studying this chapter, you should be able to:

1.  Recall the anatomy and physiology of the gastrointestinal (GI) system.

2.  Perform a GI assessment using Gordon’s Functional Health Patterns.

3.  Evaluate important assessment findings in a client with a GI health problem.

4.  Explain the use of laboratory testing for a client with a GI health problem.

5.  Identify the use of radiography in diagnosing GI health problems.

6.  Plan follow-up care for clients having endoscopic procedures.

 

The gastrointestinal (GI) system includes the GI tract, consisting of the mouth, esophagus, stomach, small and large intestines, and rectum. The salivary glands, liver, gallbladder, and pancreas secrete substances into the GI tract by connect­ing ducts (Figure 53-1). The adult GI tract is approximately 15 feet long. The main function of the GI tract, with the aid of or­gans such as the pancreas and the liver, is the digestion of food. Nutritional assessment is discussed in Chapter 61. The GI tract is susceptible to many pathologic conditions, including struc­tural problems, impairments in motility, infection, and cancer.

ANATOMY AND PHYSIOLOGY REVIEW

 Overview of the Gastrointestinal Tract

Structure

The GI tract consists of a hollow tube—the lumen—sur­rounded by a layer of surface and epithelial cells called the mucosa. The mucosa includes a thin layer of smooth muscle and some exocrine gland cells. This layer is surrounded by the submucosa, which is made up of connective tissue. The out­ermost layer is composed of both circular and longitudinal smooth muscles, which work to keep contents moving through the tract. Although the GI tract is continuous from the mouth to the anus, it is divided into specialized regions. The mouth, pharynx, esophagus, stomach, and small and large in­testines each perform a specific function. In addition, the se­cretions of the salivary, gastric, and intestinal glands; liver; and pancreas empty into the GI tract to aid digestion.

Function

The functions of the GI tract include secretion, digestion, ab­sorption, and motility. Food and fluids are ingested, swallowed, and propelled along the lumen to be eliminated. Contractions of the smooth muscles in the GI tract move food from the mouth to the anus. Before food can be absorbed, it must be dissolved and broken down. Digestion is a mechanical and chemical process whereby complex foodstuffs are broken down into sim­pler forms that can be used by the body. During digestion, the stomach secretes hydrochloric acid, the liver secretes bile, and digestive enzymes are released, aiding in food breakdown. Af­ter the digestive process is complete, absorption takes place. Absorption is carried out as the nutrients produced by digestion move from the lumen of the GI tract into the body’s circulatory system for uptake by individual cells (Figure 53-2).

 Nerve Supply

Innervation of the GI tract occurs in two ways. First, intrinsic contractile stimulation is provided by two internal nerve plexuses: the my enteric plexus (an outer plexus found in the longitudinal and circular smooth muscle) and the submucosal plexus (an inner nerve plexus in the submucosa). These nerve plexuses connect with each other along the entire length of the GI tract to maintain the tone of the smooth muscle and to stimulate movements.

The second type of innervation is provided by the auto-nomic nervous system, which connects with nerve fibers from the intrinsic nerve plexuses. Parasympathetic stimulation is provided primarily by the vagus nerve (cranial nerve X), which innervates the esophagus, the stomach, and to a lesser extent, the small intestine, the gallbladder, and part of the large intestine. This stimulation causes increased motor and secretory activity and relaxation of sphincters. Sympathetic stimulation via the thoracic and lumbar splanchnic nerves is provided to all parts of the GI tract; it slows movement, in­hibits secretions, and contracts sphincters.

 

Blood Supply

The blood supply to the GI tract originates from the aorta and branches to the many arteries throughout the length of the tract: the celiac, gastric, splenic, common hepatic, internal and external iliac, and superior and inferior mesenteric arter­ies. The venous system that carries absorbed nutrients away from the lumen of the GI tract consists of the gastric vein, the splenic vein, and other veins that drain into the portal vein of the liver. This blood circulates through the liver to the hepatic vein and returns to the heart via the inferior vena cava.

Oral Cavity

Structure

The oral cavity includes the buccal mucosa, lips, tongue, hard palate, soft palate, teeth, and salivary glands. The buccal mu­cosa is the mucous membrane lining the inside of the oral cav­ity. The lips are external to the oral cavity and are pink-red. The tongue lies on the floor of the mouth, anchored to the hyoid bone. The tongue is involved in speech, taste, and masti­cation (chewing). The mucous membrane covering the tongue consists of small projections, called papillae, that house the taste buds and provide a roughened surface, permitting the movement of food in the mouth during chewing. The hard palate and the soft palate together form the roof of the mouth.

Adults have 32 permanent teeth: 16 in each arch. The teeth are composed of a hard, calcified substance called dentin, which is then covered by enamel. There are four types of teeth: incisors, canines, premolars, and molars. The oral cav­ity contains three major salivary glands: the parotid glands, the submandibular glands, and the sublingual glands. These glands produce 1 to 1.5 L of saliva per day to assist in diges­tion by moistening food, thus enabling it to be formed into a bolus for swallowing.

The pharynx (throat) extends from the soft palate to the esophagus. It is lined with mucous membrane and contains three pairs of organs: the adenoids, the lingual tonsils (at the base of the tongue), and the tonsils.

 

 Function

The different types of teeth function to prepare food for di­gestion by cutting, tearing, crushing, or grinding the food. Swallowing begins after food is taken into the mouth and chewed. Saliva is secreted in response to the presence of food in the mouth and begins to soften the food. Saliva contains mucin and an enzyme, salivary amylase (also known as ptyalin), which begins the breakdown of carbohydrates.

The four phases of swallowing are oral preparatory, oral, pharyngeal, and esophageal. The oral preparatory phase be­gins with the intake of food into the mouth. The mandible, teeth, and tongue work to soften the food and form a bolus. The tongue acts to move the bolus toward the back of the mouth. The oral phase begins with the movement of the bo­lus toward the back of the mouth. The tongue presses the bo­lus against the hard palate, toward the anterior faucial arches, triggering the swallowing reflex.

The pharyngeal phase begins as the swallowing reflex is triggered. As the bolus is forced into the pharynx, the soft palate elevates, which seals the nasal cavity. At this time, the swallowing reflex also inhibits respiration and allows the opening of the esophagus so that the food can enter. The oral and pharyngeal phases are extremely rapid, usually taking less than 1 second.

The esophageal phase begins when the bolus enters the esophagus at the cricopharyngeal juncture. A peristaltic wave passes the food to the stomach, which takes about 9 seconds.

Esophagus

Structure

The esophagus is a muscular canal approximately 10 inches (24 cm) long; it extends from the pharynx to the stomach and passes through the hiatus in the center of the diaphragm. The wall of the esophagus consists of mucosa, submucosa, and muscularis propria. The mucosal layer is composed of squa-mous epithelial cells. The submucosa is composed of loose connective tissue containing blood vessels, lymphatics, and nerve fibers. The muscularis propria consists of smooth and striated muscle fibers. The portion of the esophagus proximal to the gastroesophageal junction is referred to as the lower esophageal sphincter (LES).

Function

The primary function of the esophagus is to propel food and fluids from the pharynx to the stomach and to prevent reflux of gastric contents into the esophagus. The propulsive func­tion is the result of coordinated contractions of the muscular layers of the esophagus. The esophageal walls secrete mucus to lubricate the food and aid in the transport of the bolus to the stomach. As peristalsis pushes the bolus along the esophagus, the cardiac sphincter relaxes to allow the bolus to enter the stomach. The activity of the LES is regulated by smooth mus­cle, as well as neural and hormonal influences.

Stomach

Structure

The stomach is a glandular digestive and endocrine organ lo­cated in the midline and left upper quadrant (LUQ) of the ab­domen. The stomach has four anatomic regions. The cardia is the narrow portion of the stomach that is distal to the gastro­esophageal junction. The fundus is the area to the left above the gastroesophageal junction. The main area of the stomach is referred to as the body or corpus. The antrum is the distal portion of the stomach and is separated from the duodenum by the pyloric sphincter. Both ends of the stomach are guarded by sphincters (cardiac and pyloric), which aid in the transport of food through the gastrointestinal (GI) tract and also prevent backflow (Figure 53-3).

The surface of the stomach is covered with rugae, or folds of mucosa and submucosa that extend longitudinally. Smooth muscle cells that line the stomach are responsible for gastric motility. The stomach is also richly innervated with intrinsic and extrinsic nerves. Parietal cells lining the wall of the stom­ach secrete hydrochloric acid, whereas chief cells secrete pepsinogen (a precursor to pepsin, a digestive enzyme). Pari­etal cells also produce intrinsic factor, which works to facili­tate the absorption of vitamin B₁₂.

Function

The stomach performs several functions. Following ingestion of food, the stomach functions as a food reservoir. The stom­ach serves a secretory function that aids digestion. Gastric se­cretion can be divided into three phases: cephalic, gastric, and intestinal.

The cephalic phase begins with the sight, smell, and taste of food and is regulated by the vagus nerve. Sympathetic nerve fibers activate neurons in the GI nerve plexus, which then serve to initiate secretory and contractile activity. The gastric phase begins with the presence of food in the stomach. The G-cells in the antrum secrete the hormone gastrin, which promotes the secretion of hydrochloric acid and pepsinogen.

Hydrolochloric acid transforms inactive pepsinogen into active pepsins, which aid in the digestion of proteins. The secretion of mucus and bicarbonate protect the stomach from mechan­ical and chemical damage. The fluids secreted into the stom­ach are collectively referred to as gastric juice (Table 53-1). Intrinsic factor is secreted by parietal cells, which bind vita­min B₁₂ to enhance its absorption in the ileum.

The stomach also mixes or churns the food, breaking apart the large food molecules and mixing them with gastric secre­tions to form chyme, which then empties into the duodenum. The intestinal phase begins as the chyme passes from the stomach into the duodenum, causing distention. The intestinal phase is mediated by secretin, a hormone that inhibits further acid production and decreases gastric motility.

Pancreas

Structure

The pancreas lies retroperitoneally in the upper abdominal cav­ity behind the stomach and extends horizontally from the duo­denal C-loop to the spleen. The pancreas is divided into por­tions known as the head, the body, and the tail (Figure 53-4).

  Function

Two major cellular bodies within the pancreas have separate functions: exocrine and endocrine. The exocrine part of the pancreas constitutes approximately 80% of the organ and con­sists of acinar cells, which secrete the enzymes that are neces­sary for the digestion of carbohydrates, fats, and proteins (trypsin, chymotrypsin, amylase, and lipase) (Table 53-2). The endocrine part of the pancreas is made up of the islets of Langerhans, with alpha cells producing glucagon and beta cells producing insulin. Although the islet cells account for less than 2% of the volume of the pancreas, the hormones pro­duced are essential in the regulation of metabolism. Chapter 62 describes the endocrine function of the pancreas.

Liver

Structure

The liver is the largest organ in the body and is mainly located in the right upper quadrant (RUQ) of the abdomen. The liver is divided into two major regions: a larger right lobe and a smaller left lobe. The lobes are divided by the falciform liga­ment, which attaches the liver to the diaphragm. The liver is made up of functioning units called lobules (Figure 53-5). The organ has a connective tissue covering, called the Glisson cap­sule, which protects it. Hepatocytes, or liver cells, are arranged into cellular plates, which radiate from a central vein. Small bile channels fit between the plates and empty into terminal bile ducts. The right and left hepatic ducts transport bile from the liver. The liver receives its blood supply from the hepatic artery and the hepatic portal vein. Approximately 1500 mL of blood flows through the liver every minute.

Function

The liver performs more than 400 functions in three major cat­egories: storage, protection, and metabolism. The liver stores several minerals and vitamins: copper, iron, magnesium, vita­min B_I2, folic acid, vitamin B₆, niacin, and the fat-soluble vita­mins A, D, E, and K.

The protective function of the liver involves phagocytic Kupffer’s cells, which are part of the body’s reticuloendothelial system. They engulf harmful bacteria and anemic red blood cells. The liver also detoxifies potentially harmful compounds (such as drugs, chemicals, and alcohol) that are ingested.

The liver functions in the metabolism of proteins consid­ered vital for human survival. It breaks down amino acids to remove ammonia, which is then converted to urea and is ex­creted via the kidneys. In addition, the liver synthesizes sev­eral plasma proteins, including albumin, prothrombin, and fibrinogen. The liver’s role in carbohydrate metabolism in­volves storing and releasing glycogen as the body’s energy re­quirements change. The liver synthesizes, breaks down, and temporarily stores fatty acids and triglycerides.

 

 

The liver forms and continually secretes bile. Bile is essential for the emulsification of fat. The constituents of bile are bile salts, cholesterol, phospholipids (lecithin), water, electrolytes, and bile pigments (bilirubin). The secretion of bile increases in response to gastrin, secretin, and cholecystokinin. Bile is se­creted into small ducts that empty into the common bile duct and into the duodenum at the sphincter of Oddi. However, if the sphincter is closed, the bile goes to the gallbladder for storage.

Gallbladder

Structure

The gallbladder is a pear-shaped bulbous sac that is located on the inferior surface of the liver. The gallbladder has three por­tions: the neck, which is continuous with the cystic duct; the body, or main portion; and the fundus, the lower bulbous section. The gallbladder is drained by the cystic duct, which joins with the hepatic duct from the liver to form the common bile duct.

 

 Function

The gallbladder concentrates and stores the bile that has come from the liver. It releases the bile into the duodenum via the common bile duct when fat is present.

Small Intestine

1 Structure

The small intestine is the longest and most convoluted portion of the digestive tract. It is composed of three different regions: the duodenum, the jejunum, and the ileum. The duodenum is the first 10 inches (25 cm) of the small intestine and is attached to the distal end of the pylorus. It is C-shaped, curving left around the head of the pancreas and bending behind the transverse portion of the large intestine. The common bile duct and pancreatic duct join to form the ampulla of Vater, emptying into the duodenum at the duodenal papilla. This papillary opening is surrounded by sphincter muscle known as the sphincter of Oddi. The 8-foot (2.5-m) portion of the small intestine that follows the sphincter of Oddi is the je­junum. The last 8 to 12 feet (2.5 to 4 m) of the small intestine is called the ileum. The ileocecal valve separates the entrance of the ileum from the cecum of the large intestine.

The inner surface of the small intestine has circular folds of mucosa and submucosa called plicae circulares, which project into the lumen to increase the surface area for diges­tion and absorption. Villi, microscopic finger-like projections, cover the plicae circulares to further increase the absorptive surface of the small intestine. The mucosa contains intestinal glands located between the villi.

Function

The small intestine has three main functions: movement (mix­ing and peristalsis), digestion, and absorption. The small in­testine mixes and transports the chyme by movements called segmental contractions. The contents are moved back and forth over short distances, thereby allowing the chyme to mix with many digestive enzymes. The ileocecal valve opens only to allow the passage of chyme. It takes an average of 3 to 10 hours for the contents to be propelled by peristalsis through the small intestine. The intestinal glands secrete intestinal juice containing epithelial cells that are used to replace sur­face epithelial cells of the villi as they are lost. The intestinal cells also produce cells that contain enzymes aiding in the di­gestion of proteins, carbohydrates, and lipids.

Many digestive hormones and enzymes aid in the digestion of the chyme, each having a specific function (see Tables 53-1 and 53-2). Carbohydrates, fats, proteins, vitamins, water, and electrolytes are absorbed by both diffusion and active transport.

Large Intestine

Structure

The large intestine extends approximately 5 to 6 feet in length from the ileocecal valve to the anus and is lined with colum­nar epithelium that has absorptive and mucous cells. It begins with the cecum, with the appendix forming a narrow tube ex­tending down from the cecum. The large intestine then ex­tends upward from the cecum as the colon. The colon consists of four divisions: the ascending colon, the transverse colon, the descending colon, and the sigmoid colon. The sigmoid colon empties into the rectum.

Following the sigmoid colon, the large intestine bends downward to form the rectum. The last 3 to 4 cm of the large intestine is called the anal canal, which opens to the exterior of the body through the anus. The anal canal is surrounded by sphincter muscles.

Function

The large intestine’s functions are movement, absorption, and elimination. Movement in the large intestine consists mainly of segmental contractions, like those in the small intestine, to allow enough time for the absorption of water. In addition, three or four strong peristaltic contractions per day are trig­gered by colonic distention in the proximal large intestine to propel the contents toward the rectum, where the material is stored until the urge to defecate occurs.

Absorption of water and some electrolytes occurs in the large intestine to reduce the fluid volume of the chyme, which creates a more solid material, the feces, for elimina­tion. GI changes associated with aging are summarized in Chart 53-1.

ASSESSMENT TECHNIQUES

 History

One method of assessing gastrointestinal (GI) functioning is to use the nutritional-metabolic and elimination patterns found in Gordon’s Functional Health Patterns (Chart 53-2). The goal of the health history is to determine the events re­lated to the current health problem.

 

GASTROINTESTINAL ASSESSMENT Using Gordon’s Functional Health Patterns

Nutritional-Metabolic Pattern

What is your typical daily food intake? Describe a day’s

meals, snacks, and vitamins. How much salt do you typically add to your food? Do you

use salt substitutes?

How is your appetite? Any recent change? Do you have any difficulty chewing or swallowing? Do you wear dentures? How well do they fit? Do you ever experience indigestion or “heartburn”? How

often? What seems to cause it? What helps it? Do you have pain, diarrhea, gas, or any other problems?

Do any specific foods cause this for you? What is your typical daily fluid intake? What types of fluids

(water, juices, soft drinks, coffee, tea)? How much? Have you had any recent change in your weight? Weight

gain? Weight loss? How much? Have you noticed a change in the tightness of your rings or

shoes? Tighter? Looser? Have you noticed any difference in the size of your

abdomen?

Elimination Pattern

What is your usual bowel elimination pattern? Frequency?

Character? Discomfort? Laxatives? Do you have any pain or bleeding associated with bowel

movements? Have you experienced any changes in your usual bowel

pattern?

When was your last rectal examination? Have you ever had an endoscopy or a colonoscopy? What is your usual urinary elimination pattern? Frequency?

Amount? Color? Odor? Control? Have you noticed a change in the amount of urine?

Based on Gordon, M. (2000). Manual of nursing diagnosis (9th ed). St. Louis: Mosby.

DEMOGRAPHIC DATA

The nurse or assistive nursing personnel collects demographic data about the client, such as age, gender, culture, and occu­pation. This information can provide information regarding predispositions to particular GI tract disorders. For example, familial adenomatous polyposis (FAP) is an inherited autoso-mal dominant disorder that predisposes the client to colon cancer.

CONSIDERATIONS FOR OLDER ADULTS

The majority of GI tract cancers occur in adults age 50 and older. In addition, the incidence of hiatal hernia increases with each decade of life. Diverticulosis and gallstones are also seen increasingly in people older than 40 years of age.

 CULTURAL CONSIDERATIONS

Inflammatory bowel diseases are more common in Cau­casians than in African Americans or Asians. Ulcerative colitis is three to six times more prevalent among people of Jewish descent (Glickman, 1998). The incidence of GI cancers also varies among ethnic groups. For example, gastric cancer is prevalent in Japan, Korea, and southern China. Colon cancer is more prevalent among African-American men (Garlick Roll, 1999; Hawkins, 1999).

PERSONAL AND FAMILY HISTORY

A thorough review of the client’s overall health status is an important part of every history. The nurse questions the client about previous GI disorders or abdominal surgery.

The client is asked about prescription medications being taken, including how much, when the drugs are administered, and why they have been prescribed. The nurse also explores whether the client takes over-the-counter medications, which he or she may use independently. In particular, the nurse asks whether aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs) (such as ibuprofen), laxatives, or enemas are rou­tinely taken. Large amounts of aspirin or NSAIDs can predis­pose the client to peptic ulcer disease and GI bleeding. Long-term use of laxatives or enemas can cause dependence on such stimulation and result in constipation.

Finally, the nurse investigates the client’s travel history. The nurse asks the client whether he or she has traveled out­side of the country recently. This information may provide clues as to the origin of symptoms such as diarrhea.

 DIET HISTORY

A diet history is important when assessing GI tract function. Many conditions of the GI tract manifest themselves as a re­sult of alterations in dietary intake and absorption of nutrients. The goals of a nutritional assessment are to gather informa­tion about ingestion, digestion, absorption, and metabolism (Hammond, 1999). The nurse inquires about any special diet and whether there are any known food allergies. The nurse also asks the client to describe the usual foods that are eaten daily and the times meals are taken.

The nurse explores with the client any changes that have occurred in eating habits as a result of illness. Anorexia (loss of appetite for food) can occur with GI disease. The nurse also asks about changes in taste and any difficulty or pain with swallowing (dysphagia) that could be associated with esophageal disorders. The nurse ascertains if abdominal pain or discomfort accompanies eating, and if the client has expe­rienced any nausea, vomiting, or dyspepsia (indigestion or heartburn). Unknown food allergies often cause these symp­toms. The nurse inquires about any unintentional weight loss, since some cancers of the GI tract may present in this manner. It is also important to assess alcohol and caffeine consump­tion, because both substances are associated with many GI disorders, such as gastritis and peptic ulcer disease.

CULTURAL CONSIDERATIONS

Cultural and religious patterns are important in obtain­ing a complete diet history. The nurse determines if culturally based foods pose a problem for the client. For example, the spices or hot pepper used in cooking in many cultures can ag­gravate or precipitate GI tract complaints, such as indigestion. The nurse should also note religious patterns such as fasting or abstinence.

Approximately 80% to 90% of African Americans are lactose intolerant (Greenberger & Isselbacher, 1998). A much smaller percentage of Caucasians also have this problem. Lactose in­tolerance causes bloating, cramping, and diarrhea as a result of lack of the enzyme lactase. Lactase is needed to convert lac­tose in milk and other dairy products to glucose and galactose.

SOCIOECONOMIC STATUS

Knowledge of the client’s socioeconomic status can give the nurse valuable clues for determining his or her ability to obtain food, medications, and medical care. People who have limited budgets, such as elders or the unemployed, may not be able to purchase foods required for a balanced diet. In addition, they may substitute less expensive, and perhaps less effective, over-the-counter medications for prescription medications. Necessary medical care may be delayed, and clients may not seek health care until condi­tions are well advanced. Clients who are financially re­stricted may benefit from suggestions for managing nutri­tion while on a budget.

CURRENT HEALTH PROBLEMS

GI tract clinical manifestations are often vague and difficult for the client to describe. The nurse obtains a chronologic ac­count of the current problem, symptoms, and any treatments taken. Furthermore, the nurse explores the characteristics as­sociated with each symptom, including the location, quality, quantity, timing (onset, duration), and factors that may aggra­vate or alleviate the symptom (see Chart 53-2). The following examples are topics to explore with clients about specific GI tract symptoms.

A change in bowel habits is a significant complaint. The nurse explores the following with the client:

•    Pattern of bowel movements

•    Color and consistency of the feces

•    Occurrence of diarrhea or constipation

•    Effective action taken to relieve diarrhea or constipation

•    Presence of frank blood or tarry stools

•    Presence of abdominal distention or gas

An unintentional weight gain or loss is a symptom that warrants further investigation. The nurse assesses the client concerning the following:

•   Normal weight

» Weight gain or loss

•    Period of time for weight change

•    Changes in appetite or oral intake

Smoking predisposes the client to several types of cancer, especially oral cancer, because nicotine is a GI irritant. The nurse obtains a smoking history, including the number of packs of cigarettes smoked per day per number of years. The nurse also asks about any history or current use of cigars, pipe to­bacco, or chewing tobacco.

Pain is a common complaint in clients with GI tract disor­ders. The nurse asks about pain in relation to the following:

•    Presence

•    Location

•    Radiation to another site

•    Factors that make the pain better or worse

•    Intensity

Abdominal pain is often vague and difficult to evaluate. Asking the client to apply descriptors to the type of pain, such as burning, gnawing, or stabbing, is often helpful. The location of the pain can be determined by asking the client to point to the involved site. The nurse also asks about the relationship of food intake to the onset or worsening of pain. For example, a high-fat meal often triggers gallblad­der pain.

Changes in the skin can result from several GI tract disor­ders, such as liver and biliary system obstruction. The nurse asks the client about the following:

·         Skin discolorations or rashes

·         Itching

·         Jaundice

·         Increased susceptibility to bruising

·          Increased tendency to bleed

Physical Assessment

Physical assessment of the gastrointestinal (GI) system in­volves a comprehensive examination of the client’s nutritional status, the mouth and pharynx, the abdomen, and the extremi­ties. Nutritional assessment is discussed in detail in Chapter 61.

 MOUTH AND PHARYNX

Assessment of the mouth involves inspection and palpation. To begin the examination of the mouth, the nurse puts on gloves, faces the client, and inspects the lips for color, mois­ture, cracking, or lesions. To continue, the nurse needs a pen-light and a tongue depressor. The medical-surgical nurse in­spects the inner surfaces of the lips and the oral mucosa, starting on the client’s left side and moving in a clockwise fashion. The advanced-practice nurse (APN) carefully pal­pates the U-shaped area under the tongue for nodules, since oral malignancies are most likely to develop in this area. The tongue is inspected for color, coating, ulcers, and variations in size and shape.

The nurse examines the teeth for evidence of dental caries and notes the absence of teeth. Tooth discoloration may be the result of excessive tobacco use. Referral to a dentist is appro­priate if the nurse detects abnormalities or decay.

The gums should be pink, moist, and smooth. African-American clients may have a dark line on the margins of the gingiva. If the client wears dentures, they are removed. Throughout this examination, the nurse is alert to any signifi­cant mouth odors that suggest disease. For instance, a fruity smell may indicate uncontrolled diabetes mellitus.

Oral lesions or nodules are noted. For example, lesions from Kaposi’s sarcoma may be seen in clients with acquired immunodeficiency syndrome (AIDS).

 ABDOMEN

In preparation for examination of the abdomen, the client is instructed to empty his or her bladder and then to lie in a supine position with the knees bent, keeping the arms at the sides to prevent inadvertent tensing of the abdominal muscles. During the abdominal examination, the nurse usually be­gins at the client’s right side and proceeds in a systematic fashion (Figure 53-6):

•    Right upper quadrant (RUQ)

•    Left upper quadrant (LUQ)

•    Left lower quadrant (LLQ)

•    Right lower quadrant (RLQ)

Table 53-3 lists the organs that lie in each of these topo­graphic areas.

If areas of pain or discomfort are noted from the history, the nurse places this area last in the examination sequence. This sequence should prevent the client from tensing abdominal muscles because of the pain, which would make the examina­tion difficult. The nurse examines any area of tenderness cau­tiously and instructs the client to state whether it is too painful. His or her face is observed for signs of distress or pain.

 

The nurse assesses the abdomen by using the four tech­niques of examination, but in a sequence different from that used for other body systems: inspection, auscultation, percus­sion, and then palpation. This sequence is preferred so that palpation and percussion do not increase intestinal activity and hence increase bowel sounds. Palpation is not performed if appendicitis or an abdominal aneurysm is suspected.

 Inspection

The nurse inspects the skin and notes the following:

·         Overall symmetry of the abdomen

·         Presence of discolorations (rashes, lesions, striae, petechiae, scars, distended superficial veins, jaundice, and any other pigmentation changes)

·         Abdominal distention

·         Bulging flanks

·         Taut, glistening skin

The nurse assesses the architecture of the abdomen by ob­serving its contour and symmetry. The contour of the abdomen is the abdominal profile and can be rounded, flat, concave, or distended. The contour is best seen if one stands at the side of the bed. The nurse notes whether the contour is symmetric or asymmetric. Asymmetry in the upper quadrants can be indica­tive of a tumor, pancreatic cyst, or gastric dilation. Asymmetry in the lower quadrants can be caused by ovarian tumors, fibroid tumors, pregnancy, or bladder distention (O’Hanlon-Nichols, 1998). The nurse inspects the shape and position of the umbilicus for any deviations. The presence of ecchymosis around the umbilicus (Cullen’s sign) is also noted as an indication of in-traperitoneal hemorrhage (Wrobleski, Barth, & Oyen, 1999).

Finally, the nurse inspects the client’s abdominal move­ments, including the normal rising and falling with inspiration and expiration, and notes any distress during movement. Oc­casionally, pulsations may be visible, particularly in the area of the abdominal aorta. Peristaltic movements are rarely seen on inspection unless the client is thin and has markedly in­creased peristalsis. If such movements are observed, the nurse notes the quadrant of origin and the direction of peristaltic flow. This finding is reported to the health care provider, since it may indicate an intestinal obstruction.

 Auscultation

The nurse performs auscultation of the abdomen with the di­aphragm of the stethoscope, since bowel sounds are usually high pitched. The stethoscope is placed lightly on the abdom­inal wall while the nurse listens for bowel sounds in all four quadrants, beginning in the RLQ at the ileocecal valve area.

Bowel sounds are created as air and fluid move through the GI tract. They are normally heard as relatively high pitched gurgles every 5 to 15 seconds, with a normal frequency range of 5 to 30 per minute. Bowel sounds are characterized as nor­mal, hypoactive, or hyperactive. The nurse listens for the character and frequency of the sounds. Bowel sounds may be irregular, so the nurse must listen for at least 1 full minute in each quadrant to confirm the absence of bowel sounds. Bowel sounds are diminished or absent after abdominal surgery or in the client with peritonitis or paralytic ileus. Increased bowel sounds, especially loud gurgling sounds, result from hyper-motility of the bowel (borborygmus). These sounds are usu­ally heard in the client with diarrhea or gastroenteritis or above a complete intestinal obstruction.

The nurse also auscultates the abdomen for vascular sounds or bruits (“swooshing” sounds) over the abdominal aorta, the renal arteries, and the iliac arteries. A bruit heard over the aorta usually indicates the presence of an aneurysm. If this sound is heard, the nurse discontinues the examination and notifies the health care provider immediately.

The nurse may auscultate for two other abnormal circula­tory sounds: friction rubs and venous hums. A friction rub, which sounds like two pieces of leather rubbing together, can be heard over the spleen or the liver and indicates the presence of a splenic infarct or a hepatic tumor. A continuous venous hum is heard in the periumbilical region in the presence of en­gorged liver circulation, as in hepatic cirrhosis.

Percussion

Percussion may be used during the abdominal assessment to determine the size of solid organs; to detect the presence of masses, fluid, and air; and to estimate the size of the liver and spleen. This part of the physical assessment is usually per­formed by a physician or advanced-practice nurse (APN). The examiner elicits percussiootes by placing the middle finger of the nondominant hand over the abdominal area to be per­cussed, striking his or her finger lightly with the tip of the middle finger of the dominant hand several times. Each quad­rant is systematically assessed by comparing sounds over dif­ferent areas. The percussiootes normally heard in the ab­domen are termed tympanic (the high-pitched, loud, musical sound of an air-filled intestine) or dull (the medium-pitched, softer, thudlike sound over a solid organ, such as the liver).

To percuss the size of the liver span, the physician or APN begins from below the right nipple in the midclavicular line and is careful to percuss between ribs. The percussioote should change from resonance of the lung tissue to dullness of the liver when the upper liver border is reached. The examiner marks the area where percussion tones change, then percusses up from the iliac crest in the midclavicular line until the per­cussioote changes from tympany of the bowel to dullness of the liver at the lower border. Again, this area is marked. The distance between the two marks is the approximate liver span, which is normally 2.4 to 5 inches (6 to 12 cm). An enlarged liver span indicates hepatomegaly (liver enlargement).

The examiner may use percussion techniques to determine the size and position of the spleen at the tenth intercostal space in the left midaxillary line. Dullness heard forward of the midaxillary line or in the left anterior axillary line indi­cates enlargement of the spleen (splenomegaly). Mild to mod­erate splenomegaly can be detected before the spleen be­comes palpable. Percussion can also be used to detect a distended bladder.

Palpation

The purpose of palpation is to determine the size and location of abdominal organs and to assess for the presence of masses or tenderness. Palpation of the abdomen consists of two types: light palpation and deep palpation. Only physicians and APNs, such as clinical nurse specialists and nurse practition­ers, should perform deep palpation.

LIGHT PALPATION

The technique of light palpation is used to detect large masses and areas of tenderness and to help the client achieve muscular relaxation. The nurse places the first four fingers of the palpating hand close together and then places them lightly on the abdomen and proceeds smoothly and systematically from quadrant to quadrant. The abdomen is depressed to a depth of 0.5 to 1 inch (1.25 to 2.5 cm), and the assessment proceeds with a rotational movement of the palpating hand. Any areas of tenderness or guarding are noted, because these areas are examined last and cautiously during deep palpation. While performing light palpation, the nurse is alert to signs of rigid­ity, which, unlike voluntary guarding, is a sign of peritoneal inflammation. Areas of pain should be evaluated for rebound tenderness (Blumberg’s sign). With fingers placed at a 90-degree angle in relation to the abdomen, the examiner pushes slowly and deeply, releasing quickly. Pain felt on release is a positive sign for rebound tenderness and should be reported to the health care provider.

iDEEP PALPATION

Deep palpation is used to further determine the size and shape of abdominal organs and masses. The APN uses the palm and fingers of one or both hands and proceeds deliber­ately around the abdominal wall to a maximal depth. If both hands are used (bimanual palpation), one hand is placed on top of the other for palpation of a deep organ. This technique may be required in order to overcome the resistance felt by a large, obese abdomen.

There are two techniques that can be used for palpating the liver. For the first technique, the examiner stands at the client’s right side and places the left hand under the client’s back parallel to the eleventh and twelfth ribs. The right hand is placed in the right upper quadrant (RUQ) parallel to the midline. The client is then instructed to take a deep breath as the examiner presses the hand inward and upward under the rib cage until a maximal depth is reached. The liver may or may not be palpable, but the edge of the liver may be felt over the fingertips of the palpating hand as the client breathes.

The second technique for palpating the liver is the hook­ing technique. The examiner stands at the client’s right side behind the shoulder and places both hands, next to one an­other, below the lower border of the liver. The client is in­structed to take a deep breath while the nurse presses in with the fingers of both hands at the costal margin. The ex­aminer attempts to feel the lower border of the liver as it descends.

Palpation is also used to detect an enlarged spleen; how­ever, the spleen must be three times its original size before it is palpable. The same two techniques for palpating the liver are used for the spleen, but on the left side. The pancreas, the gallbladder, and the left kidney are not usually palpable in most healthy adults.

Psychosocial Assessment

Psychosocial assessment focuses on how the current com­plaint affects the client’s lifestyle. The nurse asks whether there has been any interruption of, or disturbance to, usual ac­tivities, including employment. The nurse questions about re­cent stressful events experienced. Emotional stress has been associated with the development or exacerbation of irritable bowel syndrome (IBS).

CRITICAL THINKiNG CHALLENGE

·         A male client has been admitted to your unit complain­ing of RUQ pain and fever for the last 2 days. His usual dietary pattern consists of eating at restaurants several times weekly. The symptoms began 2 hours after eating a dinner of fried foods at a local restaurant.

·          What specific areas of the history should you seek further information or clarification about?

·          What physical assessment findings would you be most likely to find during the abdominal examination?

Diagnostic Assessment

 LABORATORY ASSESSMENT

To make an accurate assessment of the many possible causes of gastrointestinal (GI) tract abnormalities, laboratory testing of blood, urine, and stool specimens can be performed.

 Blood Tests

K  COMPLETE BLOOD COUNT

A complete blood count (CBC) aids in the diagnosis of ane­mia and infection; it also detects changes in the blood’s formed elements. In adults, GI bleeding is the most frequent cause of anemia.

 CLOTTING FACTORS

Because the liver is the main site of all proteins involved in coagulation, the prothrombin time is useful in evaluating the levels of these clotting factors. Prothrombin time measures the rate at which prothrombin is converted to thrombin, a process that is dependent on most of the vitamin K-associated clotting factors. Severe acute or chronic liver damage leads to prolongation of the prothrombin time secondary to impaired synthesis of clotting proteins.

SERUM ELECTROLYTES

Many electrolytes are altered in GI tract dysfunction. For ex­ample, calcium is absorbed in the GI tract and may be meas­ured to detect malabsorption. Excessive vomiting or diarrhea causes electrolyte depletion, requiring replacement.

 SERUM ENZYME ASSAYS AND LIVER FUNCTION TESTS

Assays of serum enzymes are important in the evaluation of liver damage. Aspartate aminotransferase (AST) and ala-nine aminotransferase (ALT) are two enzymes found in the liver and other organs. These enzymes are elevated in most liver disorders, but they are highest in conditions that cause necrosis, such as severe viral hepatitis.

Elevations in serum amylase and lipase are indicative of acute pancreatitis. In acute pancreatitis, serum amylase levels begin to elevate within 24 hours of onset and remain elevated for up to 5 days unless extensive pancreatic necrosis, obstruc­tion, or a pseudocyst is present. Serum amylase and lipase measurements are the best indicators of the presence of acute pancreatitis, with elevations corresponding to pancreatitis in 75% to 80% of cases (Toskes & Greenberger, 1998; Wrobleski, Barth, & Oyen, 1999).

Bilirubin is the primary pigment in bile, which is normally conjugated and excreted by the liver and biliary system. It is measured as total serum bilirubin, conjugated (direct) biliru­bin, and unconjugated (indirect) bilirubin. These measure­ments are important in the evaluation of jaundice and in the evaluation of liver and biliary tract functioning (Hass, 1999). Elevations in direct and indirect bilirubin levels can indicate impaired secretion or conjugation.

The serum level of ammonia is also measured to evaluate hepatic function. Ammonia is normally used to rebuild amino acids or is converted to urea for excretion. Elevated ammonia levels are seen in conditions that cause hepatocellular injury, such as cirrhosis of the liver.

 TUMOR MARKERS

Two oncofetal antigens—CA19-9 and CEA—are evaluated to monitor the success of cancer therapy and to assess for the recurrence of cancer in the GI tract. These antigens may also be increased in benign GI conditions. Chart 53-3 lists blood tests commonly used by the health care provider in the diag­nosis of GI disorders.

URINE TESTS

The presence of amylase can be detected in the urine. In acute pancreatitis, there is increased renal clearance of amylase. Amylase levels in the urine remain high even after serum lev­els return to normal; therefore there may be false-positive findings associated with this particular test.

Urine urobilinogen is a form of bilirubin that is converted by the intestinal flora and excreted in the urine. Its measure­ment is useful in the evaluation of hepatic and biliary ob­struction, since the presence of bilirubin in the urine often precedes the development of jaundice (Chart 53-4).

STOOL TESTS

Several stool examinations are used in the evaluation of GI tract dysfunction (see Chart 53-4). Stool testing for occult blood is called the fecal occult blood test (FOBT). The FOBT measures the presence of blood in the stool from GI bleeding, a common finding associated with colorectal cancer.

Stool samples are collected to test for ova and parasites to aid in the diagnosis of parasitic infection. Stool samples tested for fecal fats are evaluated for steatorrhea and malabsorption. Fat is normally absorbed in the small intestine in the presence of biliary and pancreatic secretions. In malabsorption, fat is abnormally excreted in the stool.

 WOMEN’S HEALTH CONSIDERATIONS Compared with women of lower socioeconomic status, women of higher socioeconomic status are more likely to have regular physical examinations that include an annual FOBT and a proctosigmoidoscopy every 3 to 5 years after the age of 50. An annual FOBT reduces mortality from colorectal cancer in women (Allen & Phillips, 1997).

 

RADIOGRAPHIC EXAMINATIONS

Radiographic examinations and similar diagnostic procedures are useful in detecting structural and functional disorders of the gastrointestinal (GI) tract. The role of the nurse is to prop­erly prepare the client for the examination, to provide an ex­planation of the procedure, and to provide the necessary post-procedure care. As with most invasive procedures, many of the diagnostic tests outlined here require a witnessed and signed informed consent.

Flat-Plate Film of the Abdomen

A flat-plate film of the abdomen is generally the first x-ray study that the health care provider orders when diagnosing a GI problem. A flat-plate film visualizes organs in the ab­domen. This simple film has the ability to reveal abnormali­ties such as masses, tumors, and strictures or obstructions to normal movement. Patterns of bowel gas appear light on the abdominal film and can be useful in detecting ileus from ob­struction. There is no required client preparation except to wear a hospital gown and remove any jewelry or belts, which may interfere with the film.

Upper Gastrointestinal Series and Small-Bowel Series

An upper GI radiographic series is an x-ray visualization from the oral part of the pharynx to the duodenojejunal junction. The upper GI series is used to detect disorders of structure or function of the esophagus (barium swallow), stomach, or duo­denum. An extension of the upper GI series, the small-bowel follow-through (SBFT), continues the tracing of the barium through the small intestine up to and including the ileocecal junction to detect disorders of the jejunum or ileum.

CLIENT PREPARATION. The client is instructed to abstain from foods or liquids for 8 hours before the test. If possible, opioid analgesics and anticholinergic medications are withheld for 24 hours before the test, since they decrease intestinal tract motility.

The client is instructed about the barium preparation and the need to drink approximately 16 ounces of the barium. The radiology nurse or technician explains that a rotating examina­tion table will be used to assist the client in assuming the ver­tical, supine, prone, and lateral positions required for this test.

PROCEDURE. The client drinks a mixture of barium sulfate, and fluoroscopy is used to trace the barium through the esophagus and stomach. The client stands against the x-ray table for this part of the test. The table then moves the client to a lying position for more views of the stomach and duodenum. Lying in a prone position, the client drinks more barium as quickly as possible while x-ray films are taken. To attempt to make the client as comfortable as possible, a pillow for the head and a sheet to prevent chilling are supplied when­ever possible. The position changes help to coat the mucosa and identify gastroesophageal reflux and hiatal hernia.

If a small-bowel radiographic series is included, the client drinks additional barium, and more x-ray films are taken at in­tervals. This series can take several hours, depending on how long it takes the barium to reach the cecum.

FOLLOW-UP CARE. After either of these series, the nurse teaches the client to drink plenty of fluids to help elim­inate the barium. The client may be given a mild laxative or stool softener to assist in elimination of the barium. The radi­ology nurse or technician instructs the client that stools may be chalky white for 24 to 72 hours as barium is excreted. The client is informed that when all barium is passed, brown stools return. If the client is at home, he or she is instructed to report abdominal fullness, pain, or a delay in return to brown stools.

 Barium Enema

A barium enema examination, also known as a lower GI se­ries, is a radiographic visualization of the large intestine. This test is usually ordered for a client with a complaint of blood or mucus in the stool or a change in bowel pattern, such as di­arrhea or constipation. A barium enema can also detect bowel obstruction from volvulus (Korsten & Abittan, 1999). This test is usually contraindicated in clients when colon perfora­tion or fistula is suspected, since there is the potential for bar­ium to enter the venous circulation, causing cardiac arrest.

CLIENT PREPARATION. Adequate client preparation for a barium enema study is very important. The client con­sumes clear liquids 12 to 24 hours before the examination to reduce the amount of fecal matter in the bowel. The client is allowed nothing by mouth (NPO) after midnight on the night before the test. In addition, the health care provider orders a potent laxative, such as magnesium citrate, and possibly an oral liquid preparation, such as GoLYTELY, for cleaning the bowel the evening before the examination. In some cases, a cleansing enema is needed or required according to the agency’s procedure.

PROCEDURE. To begin the barium enema examination, a rectal catheter with an inflatable balloon is inserted. Approx­imately 500 to 1500 mL of barium is instilled slowly by grav­ity, and the client is instructed to hold the barium. Films are taken with the client in supine, prone, and lateral positions. He or she may experience abdominal cramps and the urge to defe­cate as the barium enema is given. This procedure can be ex­tremely uncomfortable, especially for older adults. The client is instructed to take slow, deep breaths and to hold the anal sphincter as tightly closed as possible. The test takes about 45 minutes to 1 hour. In some cases, a double-contrast study is or­dered. In this study, air is instilled to enhance the contrast and outline small lesions.

FOLLOW-UP CARE. After the study is completed, the client is allowed to expel the barium. The radiology nurse or technician teaches the client to drink plenty of fluids to assist in eliminating the barium. A laxative is given to help remove the barium from the intestinal tract. The client is informed that the stools will be chalky white for about 24 to 72 hours, until all barium is expelled.

 Percutaneous Transhepatic Cholangiography

Percutaneous transhepatic cholangiography is an x-ray study of the biliary duct system using an iodinated dye instilled via a percutaneous needle inserted into the hepatic ducts of the liver. This procedure is usually performed when a client has jaundice or persistent upper abdominal pain even after cholecystectomy.

CLIENT PREPARATION. A laxative is usually given to the client the evening before the procedure. He or she is on NPO status for 12 hours before the test, and the nurse asks

about allergies to iodine or seafood. If the client has either of these allergies, the nurse informs the health care provider. Co­agulation tests are monitored, since impaired clotting is a con­traindication to this procedure. Before the procedure begins, an intravenous (IV) infusion is started for the administration of sedatives.

PROCEDURE. The client is placed in a supine position on the fluoroscopy table. The site is prepared and draped, and a local anesthetic is injected into the skin. During the test, the client is instructed to hold his or her breath on expiration while a needle is inserted into the liver under x-ray visualiza­tion. The dye is injected slowly until the biliary tree is filled. X-ray images are taken as the dye reaches the biliary duct sys­tem. A tilt table may be used to place the client in various po­sitions to visualize the entire biliary tree. At the end of the test, the biliary ducts are aspirated of contrast medium. The procedure usually takes 30 minutes to 1 hour.

FOLLOW-UP CARE. After a percutaneous transhepatic cholangiography, the client is confined to bed for 6 hours. The nurse checks vital signs frequently, since there is a risk of hemorrhage and sepsis. The client is placed on the right side with a firm pillow or sandbag placed against the lower ribs and abdomen. The nurse inspects the lower right rib cage area for signs of bleeding, hematoma, ecchymosis, or bile leakage.

Gallbladder Series

A gallbladder radiographic series, or oral cholecystography, is an x-ray visualization of the gallbladder after oral inges-tion of radiopaque, iodine-based contrast medium. It is not commonly performed today because of the availability and accuracy of gallbladder ultrasound. After the contrast medium is ingested, it is eventually cleared from the blood by the liver, and it is then deposited into the hepatic and bil­iary ducts and gallbladder. The test may be performed to identify causes of obstruction, such as stones, but gallbladder ultrasonography is more commonly done for this purpose. A gallbladder radiographic series should be done before any barium studies.

CLIENT PREPARATION. Before the gallbladder radi­ographic series, the nurse checks with the client about any al­lergies to iodine or seafood. On the day before the test, the client eats a fat-free or low-fat diet and takes 6 radiopaque io­dine tablets (iopanoic acid [Telepaque]) approximately 2 hours after the evening meal. One tablet is taken with water every 5 minutes until all 6 tablets are consumed. The nurse in­structs the client that the tablets can cause diarrhea. The client is on NPO status from midnight on the night before the test until after the test is completed.

PROCEDURE. The client is usually in the radiology de­partment for about 60 minutes while several views of the gall­bladder are taken. These films will identify any stones present in the gallbladder. The client is then given a fatty meal, or syn­thetic substitute, to cause contraction of the gallbladder within 10 to 30 minutes. A second series of films helps to con­firm the presence of contrast material in the cystic duct, com­mon duct, and duodenum.

 

FOLLOW-UP CARE. The nurse remains alert for aller­gic reaction to the contrast material.

Intravenous Cholangiography

Intravenous cholangiography (IVC) is an x-ray study of the gallbladder and biliary ducts. This test may be performed if the gallbladder is not visualized by a gallbladder radiographic series or gallbladder ultrasonography, or if biliary symptoms occur in a client who has had a cholecystectomy. It may also be done during surgery.

CLIENT PREPARATION. Before the test, the nurse checks with the client about any allergies to iodine or seafood and reports allergies to the physician. The client is on NPO status after midnight on the night before the test. Some agen­cies may require a bowel preparation. The nurse notifies the client that a sensation of warmth or flushing may be felt with the injection of the contrast medium.

PROCEDURE. The client may be in the radiology de­partment for 2 to 4 hours for IVC. The client is given an IV injection of a contrast material, and x-ray films are taken at 20-minute intervals for 1 hour, or until the biliary ducts are visualized. The gallbladder should be visualized in 1 to 2 hours.

FOLLOW-UP CARE. The radiology personnel and nurse monitor the client for allergic reaction to the contrast material so that emergency measures can be instituted if necessary.

Computed Tomography of the Gastrointestinal Tract

Computed tomography (CT), also referred to as a CT scan, is a cross-sectional x-ray visualization that can detect tissue densities and abnormalities in the abdomen, liver, pancreas, spleen, and biliary tract. CT may be performed with or with­out contrast media.

CLIENT PREPARATION. The client is instructed that he or she will need to lie still in a rather enclosed space of the machine. The client is instructed to remove jewelry or metal from the x-ray field. If the use of a contrast medium is sched­uled, the nurse asks about allergies to seafood and iodine. The client is on NPO status for 4 to 8 hours before the test if a con­trast medium is to be used. IV access will be required for in­jection of the contrast medium. The client is advised that a warm, flushing feeling may be felt on injection.

PROCEDURE. The radiologic technician instructs the client to lie still and to hold his or her breath when asked. The client is placed on the examining table, and a series of x-ray images are taken. The contrast medium may be given by IV injection for a second set of images. The test takes approxi­mately 1 to 2 hours to complete.

FOLLOW-UP CARE. No particular follow-up care is needed after a CT scan unless sedatives were administered. If the client was sedated, the nurse monitors vital signs until the client is alert and fully awake.

 CRITICAL THINKING CHALLENGE

The health care provider suspects that your client may have an inflammation of the gallbladder as a result of gallstones.

•   What diagnostic procedure will probably be ordered for this
client to confirm the diagnosis?

•   What information should the nurse ask the client about be­
fore the test is scheduled?

 . http://www.wbsaunders.com/SIMON/lggy/.

■ OTHER DIAGNOSTIC TESTS

 Endoscopy

Endoscopy is direct visualization of the gastrointestinal (GI) tract by means of a flexible fiberoptic endoscope. Endoscopes of various sizes are used for different areas of the GI tract. Vi­sualization of the esophagus, stomach, biliary system, and bowel is possible. Endoscopy is usually ordered to evaluate bleeding, ulceration, inflammation, masses, tumors, and can­cerous lesions. Obtaining specimens for biopsy and cytologic studies is also possible through the endoscope. There are sev­eral types of endoscopic examinations.

 ESOPHAGOGASTRODUODENOSCOPY

Esophagogastroduodenoscopy (EGD), a visual examination of the esophagus, stomach, and duodenum, is accomplished using a fiberoptic endoscope. The distal end of the endoscope is flexible, allowing visualization of the entire area.

CLIENT PREPARATION. The client preparing for an upper GI endoscopic examination is usually on NPO status af­ter midnight on the night before the test, or 8 to 12 hours before the procedure. The nurse explains that during the test a flexible tube is passed down the esophagus with the client under con­scious sedation. The physician usually orders medication, such as midazolam hydrochloride (Versed), meperidine (Demerol), or diazepam (Valium, E-Pam^), to sedate the client. Atropine may be administered to dry secretions. In addition, a local anes­thetic is sprayed to inactivate the gag reflex and facilitate pas­sage of the tube. The nurse explains that this anesthetic will calm the gag reflex and that swallowing will be difficult. If the client has dentures, they are removed.

PROCEDURE. After the medications are administered, the client is usually placed in the left lateral decubitus (Sims’) position with a towel or basin at the mouth for secretions. The physician passes the tube through the mouth and into the esophagus (Figure 53-7). The procedure takes approximately 30 minutes.

FOLLOW-UP CARE. The nurse checks vital signs fre­quently as ordered (usually every 30 minutes) until the seda­tion wears off. The siderails of the bed are raised during this time. The client remains on NPO status until the gag reflex re­turns (usually in 2 to 4 hours). The nurse monitors for signs of perforation, such as pain, bleeding, or fever. The client is instructed not to drive for 12 hours following the test. He or she is informed that a hoarse voice or sore throat may persist for several days following the test. Throat lozenges can be used to relieve throat discomfort.

 

Figure 53-7 • Esophagogastroduodenoscopy allows visualiza­tion of the esophagus, the stomach, and the duodenum. If the esophagus is the focus of the examination, the procedure is called esophagoscopy. If the stomach is the focus, the procedure is called gastroscopy.

   ENDOSCOPIC RETROGRADE

CHOLANGIOPANCREATOGRAPHY

Endoscopic retrograde cholangiopancreatography (ERCP) includes visual and radiographic examination of the liver, gall­bladder, and pancreas to identify the cause and location of ob­struction. After the cannula is inserted into the main duct, a ra-diopaque dye is inserted, followed by several x-ray images. The physician may perform a papillotomy, a small incision in the sphincter around the ampulla of Vater, to remove gallstones.

CLIENT PREPARATION. The client is prepared in the same manner as for an EGD, including being on NPO status after midnight on the night before the test. The client will re­quire IV access for the administration of sedation. The nurse asks about prior exposure to x-ray dye and any sensitivities or allergies.

PROCEDURE. The endoscopic portion of an ERCP is similar to that of an EGD, except that the endoscope is ad­vanced farther, to the duodenum and into the biliary tract. Once the cannula is in the common duct, the radiologist or the radiologic technician injects contrast medium, and x-ray films are taken to evaluate the biliary tract. A tilt table assists in dis­tributing the contrast medium to all branches of the biliary tree. Following examination of the biliary tree, the cannula is directed into the pancreatic duct for examination. The ERCP lasts from 30 minutes to 2 hours.

FOLLOW-UP CARE. The nurse assesses vital signs frequently, usually every 15 minutes, until the client is stable. The nurse observes for several postprocedure complications, including cholangitis, perforation, sepsis, and pancreatitis. These problems do not occur immediately after the proce­dure but may take several hours to 2 days to develop. Colicky abdominal pain can occur secondary to the air instilled dur­ing the procedure. The client is instructed to report abdomi­nal pain, fever, nausea, or vomiting that fails to resolve. He 4r she remains on NPO status until the gag reflex returns. Once the gag reflex is intact, the client can begin taking clear fluids.

colonoscopy

Colonoscopy is an endoscopic examination of the entire large bowel. The physician may also obtain tissue biopsy specimens or remove polyps through the colonoscope. A colonoscopy is also used to evaluate the cause of chronic diarrhea or locate the source of GI bleeding.

CLIENT PREPARATION. The client should have a liq­uid diet for at least 24 hours before a colonoscopy and is usu­ally on NPO status after midnight on the night before the pro­cedure.

 CONSIDERATIONS FOR OLDER ADULTS

A complete bowel preparation (“prep”) is necessary to enable the physician to visualize the entire colon. For many clients, especially older adults, the “prep” is the worst part of the procedure, resulting in weakness and fatigue.

An oral liquid preparation for cleaning the bowel (e.g., polyethylene glycol electrolyte solution [GoLYTELY]) is given to the client the evening before the examination. The so­lution should be chilled to make it more palatable. Even though it has a salty taste, the solution should not be diluted with water or ice. The nurse instructs the client to drink the preparation quickly—8 ounces (240 mL) every 10 minutes until all 4 L are consumed. This solution produces a watery diarrhea that begins in approximately 1 hour. The bowel clears in 4 to 5 hours. In some cases, the client may require laxatives, suppositories (e.g., bisacodyl [Dulcolax]), or one or more cleansing enemas. IV access is necessary for the ad­ministration of conscious sedation.

PROCEDURE. The physician orders medication to aid in relaxation, usually midazolam hydrochloride (Versed) or meperidine (Demerol). Initially, the client is placed on the left side with the knees drawn up while the endoscope is passed into the rectum to the cecum. Air may be instilled for better visualization. The entire procedure lasts approximately 60 minutes. Atropine sulfate is kept available in case of brady-cardia resulting from vasovagal response.

FOLLOW-UP CARE. The nurse checks vital signs every 15 minutes until the client is stable. Siderails are kept up until sedation wears off. The client is observed for signs of perforation and hemorrhage. The nurse instructs the client that a feeling of fullness, cramping, and passage of flatus are expected for several hours after the test. If a polypectomy or tissue biopsy was performed, there may be a small amount of blood in the first stool after the colonoscopy. Excessive bleed­ing should be reported immediately to the health care provider (Chart 53-5). If the procedure was performed in an ambulatory care setting, the client will need another person to provide transportation home. The client should avoid driving for 8 to 12 hours after the procedure because of the effects of sedation.

 PROCTOSIGMOIDOSCOPY

Proctosigmoidoscopy is an endoscopic examination of the rectum and sigmoid colon using a flexible or rigid scope. The purpose of this test is to screen for colon cancer, investigate the source of GI bleeding, or diagnose or monitor inflamma­tory bowel disease. If proctosigmoidoscopy is used as an al­ternative to colonoscopy for colorectal cancer screening, it is recommended that screening begin at 50 to 55 years of age (Levin et al., 1999).

BEST PRACTICE/or

Care of the Client After a Colonoscopy

Do not allow the client to take anything by mouth until sedation wears off and the client is alert. Take vital signs every 15 to 30 minutes until the client is alert.

Keep the siderails up until the client is alert. Assess for rectal bleeding or blood clots. Remind the client that fullness and mild abdominal cramping are expected for several hours. Assess for manifestations of bowel perforation, including severe abdominal pain and guarding. Fever may occur later.

Assess for manifestations of hypovolemic shock, includ­ing dizziness, lightheadedness, decreased blood pres­sure, tachycardia, pallor, and altered mental status (may be the first sign).

If the procedure is performed in an ambulatory care set­ting, arrange for another person to drive the client home.

 

CLIENT PREPARATION. The client should have a liq­uid diet for at least 24 hours before a sigmoidoscopy; a cleansing enema or sodium biphosphate (Fleet’s) enema is usually given the morning of the procedure. A laxative may also be ordered the evening before the test (see the Evidence-Based Practice for Nursing box at right).

PROCEDURE. For a proctosigmoidoscopy, the client is placed on the left side in the knee-chest position or on a spe­cial table in the proctoscopic position. No sedation is re­quired. The scope is lubricated and inserted into the anus to the required depth for visualization. Tissue biopsy may be performed during this procedure. The examination usually lasts about 30 minutes.

FOLLOW-UP CARE. The client is informed that mild gas pain and flatulence may be experienced from air instilled into the rectum during the examination. If a biopsy was ob­tained, a small amount of bleeding may be observed.

 Gastric Analysis

Gastric analysis measures the hydrochloric acid and pepsin content for evaluation of gastric and duodenal disorders. There are two tests in gastric analysis: basal gastric secretion and gastric acid stimulation. Basal gastric secretion measures the secretion of hydrochloric acid between meals. If only small amounts of secretion are collected, a follow-up gastric stimulation test is given.

CLIENT PREPARATION. The client is on NPO status for at least 12 hours before the test. Alcohol, tobacco, and med­ications that may affect gastric secretion are avoided for 24 hours before the test. The nurse inserts a nasogastric (NG) tube and removes and discards the residual contents of the stomach.

PROCEDURE. The NG tube is attached to suctioning equipment for collecting the contents at 15-minute intervals for 1 hour. The nurse collects each sample and labels the time and volume of each specimen.

For the gastric acid stimulation test, the NG tube is left in place, and a drug that stimulates gastric acid secretion (e.g., pentagastrin or betazole dihydrochloride [Histalog]) is given subcutaneously. Fifteen minutes after injection of the drug, specimens are again collected at 15-minute intervals for 1 hour. The nurse collects, labels, and measures the specimens.

Depressed levels of gastric secretion suggest the presence of gastric carcinoma. Increased levels of gastric secretion in­dicate Zollinger-Ellison syndrome and duodenal ulcers (see Chapter 56).

FOLLOW-UP CARE. After the test is completed, the NG tube is removed and the client can resume normal eating patterns. No other follow-up is necessary.

 Ultrasonography

Ultrasonography is a technique in which high-frequency, in­audible vibratory sound waves are passed through the body via a transducer; the echoes of the sound waves created are then recorded. The echoes are then converted into images and photographed for analysis. Ultrasound testing is commonly used to image soft tissues, such as the liver, the spleen, the pancreas, the gallbladder, and the biliary system.

CLIENT PREPARATION. The client is usually on NPO status for 8 to 12 hours before ultrasonography of the abdomen. The nurse informs the client that it will be neces­sary to lie still during the study. He or she instructed to drink 1 to 2 L of fluid just before the test, because a full bladder is necessary for accurate visualization.

PROCEDURE. The client is placed in a prone or supine position. The technician applies insulating gel to the end of the transducer and on the area of the abdomen under study. This gel allows airtight contact of the transducer with the skin. The technician moves the transducer back and forth over the skin until the desired images are obtained. The study takes about 15 to 30 minutes.

FOLLOW-UP CARE. No follow-up care is necessary after ultrasonography.

Endoscopic Ultrasonography

Endoscopic ultrasonography (EUS) provides images of the gastrointestinal (GI) wall and high-resolution images of the digestive organs. The ultrasonography is performed through the endoscope. This procedure is useful in diagnosing the presence of lymph node tumors, mucosal tumors, and tumors of the pancreas, stomach, and rectum. The client preparation and follow-up care are similar to the preparation and follow-up care for both endoscopy and ultrasonography.

 Liver-Spleen Scan

A liver-spleen scan uses IV injection of a radioactive colloid that is taken up primarily by the liver and secondarily by the spleen. The scan evaluates the liver and the spleen for tumors or abscesses, organ size and location, and vascularity. This scan is useful in evaluating hepatocellular disease.

CLIENT PREPARATION. The nurse instructs the client about the need to lie still during the scanning. The client is assured that the colloid injection has only small amounts of radioactivity and is not dangerous. The nurse should ask fe­male clients of childbearing age if they may be pregnant or are currently breastfeeding. The radionuclide can be found in breast milk, and radiation from x-ray studies should be avoided in pregnancy.

PROCEDURE. The technician or the physician gives the radioactive injection through an IV line, and a wait of about 15 minutes is necessary for uptake. The client is placed in many different positions while the scanning takes place. No follow-up care is necessary after a liver scan.

FOLLOW-UP CARE. The client should be instructed that the radionuclide is eliminated from the body through the urine in 24 hours. Careful handwashing following toi­leting will decrease the exposure to any radiation present in the urine.