Transcript kkkkkkk - University of the West of England

UWE Bristol
Gastro-intestinal examination
Anna Neary
Gastro-intestinal examination
Introduction
This activity looks at the examination of the gastrointestinal system
as a part of a systematic patient assessment. You will need to have
completed the consultation models and the history taking activities
prior to commencing the physical examination and documentation
activities.
In this activity, you will:
1. Overview of the anatomy of the gastrointestinal tract.
2. Consider a systematic approach to the gastrointestinal
examination.
3. Determine the elements of a general survey.
4. Explore the skills required to perform an examination i.e.
Inspection, palpation and ascultation
Gastro-intestinal examination
Anatomy
The gastrointestinal tracts starts at the mouth and finishes at the
anus, it includes the oesophagus, stomach, duodenum, small and
large bowel and rectum.
Food once swallowed enters the stomach and the start of digestion
occurs. It passes through the duodenum and small bowel, where
fluid from the pancreas and bile from the liver breakdown complex
sugars, fats and proteins. These are then ready to be absorbed
through the small bowel mucosa.
The large bowel absorbs water and electrolytes.
Peristaltic contraction moves the faecal bolus to the rectum.
Dividing the abdomen into four quadrants enable you to visualise
the abdominal structures.
Gastro-intestinal examination
Dividing the Abdomen
into four quadrants:
Gastro-intestinal examination
Left Upper Quadrant (LUQ)
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Left lobe of liver
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Stomach
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Body and tail of the pancreas
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Splenic flexure of the colon
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Portions of the transverse and descending colon.
Right Upper Quadrant (RUQ)
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Right lobe of liver
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Gallbladder
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Pylorus
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Duodenum
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Head of the pancreas
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Hepatic flexure of the colon
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Portions of the ascending and transverse
colon.
Left Lower Quadrant (LLQ)
Right Lower Quadrant (RLQ)
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Lower portion of the descending colon
Sigmoid colon
Caecum and appendix
Lower portion of the ascending colon
Iloecaecal junction
Gastro-intestinal examination
Systematic Examination
There are three aspects to consider when carrying out a systematic
examination:
LOOK:
inspect
FEEL:
palpate and percuss
LISTEN:
auscultate
Gastro-intestinal examination
General Survey
First you need to take time to look at your patients overall
appearance , remembering the importance of basic assessment i.e.
airway, breathing, circulation, disability and exposure and move on
only when there is no immediate intervention in these areas. Also
consider whether your patient appears to be alert or confused or
aggressive. You will need to check their blood pressure in both
arms, heart rate, respiratory rate and pulse. Look at hands, check
for signs of cyanosis and any nail deformities.
Does you patient look pale, sweaty, are there any signs of
cyanosis, are there signs of any shortness of breath?
Think about other factors, is your patient thin or obese are they
anxious.
It is important to recognise that in patients who report upper gastrointestinal pain a cardiac cause is excluded, so ensure that you take
a detailed history and explore possible risk factors. Check for
peripheral oedema. This survey will then become your opening
words for the examination section in your documentation.
Gastro-intestinal examination
Some of the hand abnormalities that you may find with patients
who have gastrointestinal disease are outlined below:
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Clubbing – swelling of the soft tissue at the nail base, can be
due to hypoxia and congenital heart disease, lung disease,
inflammatory bowel disease and malignancies.
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Terry’s nails – transverse bands of white that cover the nail,
pink at the distal aspect, this commonly associated with liver
disease.
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Koilonychia – this is thin spooned shaped nails with edges
turning upwards, this is associated with anaemia, chronic
infections, Raynaud’s disease and malnutrition.
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Palmar erythema - redness to the palms of the hand, can be
a sign of liver disease.
•
Jaundice – yellow or orange hue colour to skin is a sign of
liver disease.
Gastro-intestinal examination
Inspection
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Look inside mouth, teeth, tongue and buccal mucosa for
ulcerations and bleeding.
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Look at eyes for signs of anaemia and jaundice
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Look at the abdomen and observe for symmetry, check for
bumps, bulges, masses, scars, striae (stretch marks),
swellings, distension and distended veins. Note the shape and
contours, the abdomen should be flat to rounded in people
with an average weight.
•
Look at the abdomen from all angles including from the side
looking for pulsations. Shining a light can aid this process as
uneven contours can be detected
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Check the umbilicus this should be inverted and midline.
Pregnancy, ascites, hernia or underlying mass may cause the
umbilicus to protrude.
Gastro-intestinal examination
The signs and symptoms that would alert you to a patient who
has a gastro-intestinal disease are:
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Abdominal pain
Constipation
Nausea and vomiting
Diarrhoea
Liver flap (patient holds their hands out in front for 30 seconds
with wrists bent back),
Spider naevi
Jaundice
Ulcerations to mouth
The likely causes of generalised abdominal distension what
are:
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Fat
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Flatus
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Foetus
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Faeces
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Fluid
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Fatal tumour
Gastro-intestinal examination
Palpation
Palpate the abdomen using light (depress approx 1.5cm) then deep ( depress approx 5 – 7.5cm) palpation. You are
assessing the size, shape, position and tenderness of major organs and to detect masses and fluid. The abdomen
should be soft and non-tender as you palpate all four quadrants. Note any lumps or bumps, masses and areas of
tenderness or resistance.
Light palpation
Deep palpation
Gastro-intestinal examination
Palpation of liver
Palpation of the liver should be
performed by placing your hand on
the right upper quadrant, with index
finger in line with the costal angle.
Ask the patient to breath in and
push hand inwards and upwards. A
liver edge should be felt.
It should feel smooth and firm and
rounded. A solid, nobbly edge may
suggest cirrhosis.
Gastro-intestinal examination
Palpation of spleen
A spleen is not palpable unless it is
enlarged.
Use your left hand under left lower
rib cage, position finger tips so they
point to axilla and press inwards
and upwards.
You can also ask the patient to take
a deep breath and feel again.
Gastro-intestinal examination
Palpation of the
kidneys
To examine the kidneys place hand
on right side of abdomen below the
costal margin, above the umbilicus
and the left hand under the back
below the liver.
Press firmly up with the left hand
and down with right.
Repeat on the left hand side.
If enlarged the kidney will be
palpable.
Gastro-intestinal examination
Palpation of aorta
Press firmly in the upper abdomen, midline and feel for pulsations.
The normal width of the aortas pulsations is 3cm or more
pulsations that are expansile suggests an abdominal aortic
aneurysm.
The measurement does not include the thickness of the abdominal
wall, this can be difficult to feel in obese patients.
Gastro-intestinal examination
Percussion
Percussion is use to detect the size and location of organs and air or fluid in the stomach or bowel. Percuss in a
systematic manner (1-9). Place middle finger flat on the abdomen starting in the right upper quadrant, using your
dominant hand tap the middle finger with the tip of your finger. There are two sounds that will be heard, over the
abdomen, dullness when percussing on a solid organ or mass and tympany when percussing over a hollow air-filled
organ.
Gastro-intestinal examination
Percussion of liver
When percussing the liver you are measuring it’s
size, start at the right mid-clavicular line where
you will start with lung resonance and percuss
down the sound changes to dullness.
Then percuss up starting in the mid clavicular
line level with umbilicus and note where the
sound changes. Measure between these two
points .
In an adult liver span ranges from 6 to 12 cm.
Size is gender, height and age dependant, e.g.
females, shorter people and people over 80
years old will have smaller livers.
Gastro-intestinal examination
Percussion of spleen
The spleen is positioned behind the midaxillary
line, when percussing anteriorly, if dullness is
found an enlarged spleen is suggested.
Gastro-intestinal examination
Percussion of the Renal angle
Percuss the renal angle with your fist with moderate force.
Tenderness here can suggest kidney inflammation.
Gastro-intestinal examination
Auscultation
Bowels sounds need to be listened for in all four
quadrants with the diaphragm of the stethoscope,
listen in a systematic manner starting in the right
upper quadrant (1-9). Place the stethoscope on
the abdominal wall and listen until a bowel sound
is heard, listen for 1-3 minutes if there are no
sounds.
Bowel sounds are high-pitched and gurgling
noises, they are irregular and vary in frequency,
pitch and intensity about 5 and 30 times a minute.
Listen for a minute, if you think bowel sound are
absent listen for longer.
Gastro-intestinal examination
Summary
You have now reached the end of this activity. Here is a summary
of the main points:
 It is important to know the anatomy of the gastrointestinal
tract prior to any examination of the gastrointestinal system.

Examine the abdomen using a systematic approach i.e.
general survey, inspection, palpation and auscultation.

Have an understanding of the normal sounds heard when
ausultating the abdomen.
Gastro-intestinal examination
References
•
Browes,N et al (2005) Browes introduction to the symptoms
and signs of surgical disease. Fourth Edition . Hodder Arnold.
London
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Douglas, G, Nicol, F and Robertson, C (2009) Macleod’s
Clinical Examination. Churchill Livingstone
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Hogan-Quigley, B, Louise Palm, M, Bickley, L (2012) Bates’
Nursing Guide to Physical Examination and History Taking.
First Edition. Lippincott, Williams and Wilkins.
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Rushforth, H (2009) Assessment made incredibly easy. First
UK Edition. Lippincott, Williams and Wilkins.
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Tortora, G and Derrickson, B (2010) Essentials of anatomy
and physiology. Wiley Plus
Gastro-intestinal examination
Guided learning (Duration: 2 hour)
1. Identify a patient in practice and under the supervision of an
Advanced Nurse Practitioner or doctor, watch a gastrointestinal
examination and then perform a gastrointestinal examination.
Use the templates provided as an aid memoir.
2. Discuss your findings with the ANP or doctor.
3. Research common gastrointestinal conditions for coeliac
disease and colorectal cancer.
4. Write a reflective piece of work about a patient you have seen
and the guidelines you have learnt.
5. You will also be able to attend a day long face to face skills
workshop to complement this learning activity