A nursing health assessment of the gastrointestinal system involves the examination of the abdomen and abdominal contents. A gastrointestinal assessment is always included as part of a routine head-to-toe assessment. And, as with any other system, knowing possible symptoms and how to focus the interview and physical assessment are important skills for nursing students to have.
To begin the study of an assessment of the gastrointestinal system, review your anatomy and physiology of the system. Some helpful facts about the gastrointestinal system are included in the article 11 Facts About the Gastrointestinal System Every Nursing Student Should Know. During a gastrointestinal assessment, a nursing student will use the skills of inspection, auscultation, percussion, and palpation. This article contains 9 Tips for Performing a Nursing Health Assessment on the Gastrointestinal System.
Tip #1 – Gather Information on Chief Complaints or Symptoms.
There are a variety of upper and lower gastrointestinal complaints or symptoms. Gathering health information about the patient’s chief complaints and symptoms will help narrow the diagnosis of the gastrointestinal system. Some chief complaints of the gastrointestinal system include nausea, vomiting, loss of appetite, change in bowel habit, diarrhea, and constipation.
Nausea and vomiting
Nausea is a sensation that comes in waves in the back of the throat, the abdomen or epigastric region that causes the patient to have the urge to vomit. Vomiting is the forceful voluntary or involuntary emptying of the stomach. This is a means of the gastrointestinal tract getting rid of an irritation. Sensory fibers stimulate the vomiting center. The abdominal muscles contract, the lower esophageal sphincter opens and the contents of the stomach are regurgitated out.
Ask the patient the following questions about nausea.
- Do you ever feel sick to the stomach?
- Do you ever feel sick to the stomach and not vomit?
- How often do you feel sick to the stomach?
- Do you ever have periods of retching?
Ask the patient the following questions about vomiting.
- Have you been vomiting?
- How often do you vomit?
- How much do you vomit at a time? Attempt to help the patient quantify.
- Do you have pain with the vomiting?
- Is the vomiting related to meals?
- Does the vomit have a smell?
- What color is the vomit?
- Does the vomit contain blood?
- Do you have any other symptoms with the vomiting?
- Is there anything that alleviates nausea? Vomiting?
- Is there anything that makes nausea or vomiting worst?
Hematemesis is red bloody or coffee ground emesis. Blackish vomit that looks like coffee ground indicates blood.
Anorexia is not the disorder Anorexia Nervosa most people think about. That disorder is the refusal to eat. Anorexia is also a symptom of abdominal problems. It is the lack or loss of appetite or intolerance to certain foods due to a gastrointestinal problem.
Ask the patient the following questions about loss of appetite or anorexia.
- Have you had any loss of appetite recently?
- Is there a food you cannot eat because it hurt your stomach?
- Are there foods that cause nausea or vomiting?
Change in bowel habit
Questions about bowel habits provide information about how the bowel is functioning. Assess elimination patterns and any changes in the characteristics of the stool.
Ask the patient the following questions about bowel habit.
- When was your last bowel movement?
- How frequently do you have a bowel movement?
- What is the consistency of the bowel movement?
- Do you have any diarrhea or constipation?
- Have you had any change in bowel habits?
- Do you have any problems having a bowel movement?
- Do you have to use laxatives?
- Can you describe the stool?
- What is the color of the stool?
- Are the stools dark, maroon-colored, or black and tarry?
Melena is black tarry stools. Hematochezia is red or maroon colored stools.
Diarrhea is the passage of loose, watery stools frequently. This occurs when the water contents of the small intestine go through the large intestine too fast. There is not enough time for the water or electrolytes to be absorbed. This can cause problems if the diarrhea is prolonged.
Ask the patient the following questions about diarrhea.
- Do you have diarrhea frequently?
- How often do you have diarrhea?
- How much do you have at a time?
- Does pain accompany diarrhea?
- What does the stool look like? Is it oily, frothy, contain pus or mucus?
- Does the stool have an unusually foul smell?
- Does the stool float?
- Do you have excessive gas with diarrhea?
Constipation is difficulty passing stools or the infrequent passage of hard stools. Sometimes the contents of the intestine move through the large intestine too slow. Too much water is reabsorbed which makes it hard for the feces to continue to move through the system. And, the longer the feces stay in the larger intestine the more water is reabsorbed. This can become a vicious circle.
Ask the patient the following question about constipation.
- How often do you have bowel movements?
- How often do you have bowel movements normally?
- Are the bowel movements painful?
- Do you have to strain with the bowel movement?
- Do you feel like you do not completely empty your rectum?
- Can you describe the stools?
- What color are the stools?
- Do you frequently use a laxative?
Tip #2 – Gather Information About Abdomen Pain
Abdominal pain is a chief complaint or symptom of the gastrointestinal system. Abdominal pain can be a benign condition or it can be life-threatening. There are several types of abdominal pain. These types of pain include visceral pain, parietal pain, and referred pain.
Visceral pain is a burning, aching, cramping, and gnawing pain. It can have additional symptoms such as nausea, vomiting, and restlessness. Visceral pain originates from the intestine or another hollow organ. Also, the pain can arise from the biliary tree. Whenever these organs are stretched beyond capacity the patient will experience visceral pain.
Parietal pain is usually more severe than visceral pain. This type of pain is a constant aching pain. It is usually localized over the organs causing the pain. If a patient moves or coughs, the pain becomes worst. These patients like to remain very still.
Referred pain is pain that is not felt at the site of origination. This type of pain can be felt in the back, over the chest or other sites. As abdominal pain becomes greater, the pain appears to radiate or travel to another site. This type of pain can be deep or superficial.
Ask the following questions to gather more information about the abdominal pain.
- Find out if the pain is acute or chronic.
- When did the pain start?
- Did the pain start suddenly or gradually?
- How long have you experienced this pain?
- Does the pain last long or does it come and go?
- Are there certain times that you feel the pain?
- Describe the pain? Is the pain aching, gnawing, cramping, burning, or stabbing?
- Point to where you feel the pain.
- Does it move or travel?
- Is there anything that aggravates the pain?
- What do you do to make the pain feel better?
- Is the pain affected by meals, alcohol, or medication?
- On a scale of 0-10, how severe is the pain?
Tip #3 – Know the Landmarks of the Abdomen
The Four Quadrants
For the purpose of assessment, the abdomen is usually divided into four quadrants. Also, the fours quadrants can be used for assessing abdominal contents. However, dividing the abdomen into the nine regions is helpful. This method divides the middle of the abdomen into the epigastric, umbilical and suprapubic regions. These regions are very useful for descriptive purposes. The four quadrants include the right upper quadrant, left upper quadrant, right lower quadrant, and left lower quadrant. Dividing the abdomen into four quadrants are used to assess bowel sounds during an abdominal assessment. The stomach is divided into the four quadrants using one horizontal plane and one vertical plane. The horizontal plane is the transumbilical. This plane crosses through the umbilicus. And, the vertical plane is the medial plane. It extends from the xiphoid process to the symphysis pubis. Below are the organs contained in the four quadrants.
Tip #4 – Inspection the Abdomen
When assessing the abdomen, remember that palpation and percussion are contraindicated in patient that you suspect of having a diagnosis of an abdominal aortic aneurysm, appendicitis and other conditions. Always check for contraindications before beginning an abdominal assessment.
To inspect the abdomen:
When assessing the abdomen it is important to make the patient as comfortable as possible.
- Position the patient in a lying position with their head on a pillow.
- Be sure and remove the clothing or lift the gown.
- Alternative positions are lying with knees bent on a pillow or a side-lying position.
- Standing on the right side is a good position to begin. This will help you flow into the rest of the assessment techniques.
- Placing yourself at eye level with the abdomen is helpful to begin the inspection.
- Upon inspection, you are looking at the surface of the abdomen.
- Inspect the skin. The skin should be smooth and even.
- Check the skin for any rashes, scars, lesions.
- Inspect the contour of the abdomen.
- Is the abdomen flat, rounded, scaphoid, or protuberant?
- Check the abdomen for any bulges or masses.
- Inspect the abdomen for symmetry. The abdomen should be symmetrical bilaterally.
- Inspect the umbilicus.
- Look for any movements of the abdomen.
- Also, check for any surgical incisions.
- Check for any types of equipment such as G-tube, drains, etc.
- Peristalsis is not normally visible but, can be visible with an intestinal obstruction.
- Check for pulsations. Pulsations can sometimes be visualized with an abdominal aneurysm.
A flat abdomen is commonly seen in a person of normal weight. There is a straight line from the costal margin to the symphysis pubis.
A rounded abdomen has a convex shape. This usually indicates additional fat around the abdominal area. A rounded abdomen is normal in pregnant women and toddlers.
A scaphoid abdomen has a concave shape. From the side, the abdomen looks sunken. This shape is usually seen in patients who are extremely thin.
A protuberant abdomen is seen in patients who are obese or have ascites. The abdomen is extremely rounded. This shape is seen in women who are pregnant but is also seen in men with ascites.
Tips #5 – Auscultate the Abdomen
Bowel sounds are auscultated to check for bowel motility.
Auscultation should occur prior to percussion and palpation as they can alter the frequency of bowel sounds.
To auscultate the abdomen:
- Use the diaphragm of the stethoscope.
- Apply light pressure
- Auscultate the abdomen in all four quadrants.
- Listen for bowel sounds, noting the characteristic and frequency.
- Listen for bruits or any vascular sounds.
Types of Bowel Sounds
Hyperactive bowel sounds are high pitched, and loud. They are caused by increased gastric motility.
Borborygmus is a type of hyperactive bowel sound. This usually occurs when your stomach growls.
Hypoactive or absent bowel sounds are a sign of decreased gastric motility.
Tip # 6 – Percussion of the Abdomen
Percussion of the abdomen is used to assess for the amount of gas in the abdomen. Also, it can be used to identify organs and masses. Percussion can help estimate the size of the liver or spleen. As mentioned in other assessment articles, to be really good at percussion you have to see it demonstrated and you also have to practice the skill. This article will cover what you should look for when percussing the abdomen. When you percuss the abdomen you are checking for the density of the contents. Also, you want to locate the different organs and any masses that may be present.
It is difficult to percuss the liver because most of it is covered by the ribcage. You have to percuss in the intercostal spaces between the ribs. Percussion of the liver is performed to distinguish the borders and the span of the liver. Dullness is heard when percussing the liver.
You are able to percuss the spleen when it enlarges. It usually extends forward, downward and to the sides. The percussion sound is dullness where the stomach is usually located. When the spleen is enlarged it can be percussed below the costal margin.
To percuss the abdomen:
- Percuss the abdomen in all four quadrants
- Assess for areas of tympany and dullness.
- Tympany is usually heard over a gas-filled area.
- Dullness is heard over solid masses or organs.
Tip #7 – Palpation of the Abdomen
Always ask the patient if they have any areas of pain before you begin palpation. Palpate the painful areas last.
Palpation of the abdomen is used to evaluate the size and location of abdominal organs. Also, you can use palpation to assess for tenderness. When palpating the abdomen, begin with light palpation. Light palpation is helpful for assessing for tenderness. Perform deep palpation to check the abdominal masses.
To lightly palpate the abdomen:
- With the fingers together, place the hand flat on the abdomen.
- Lightly palpate the abdomen using a dipping motion.
- Raise the hand off the skin while moving from one place to another.
- Palpate all four quadrants.
- Check for tenderness.
- Palpate for any superficial organs or masses.
- Notice if the patient is guarding while palpating.
To deeply palpate the abdomen:
- Use the palmer side of the hand.
- Palpate all four quadrants.
- Assess for masses noting the location, size, and shape.
- Check for tenderness.
To palpate the liver:
- Stand on the right side of the patient.
- Place your left hand behind the patient around the 11th or 12th rib.
- Have the patient relax their back onto your hand.
- Press your left hand forward as the patient relaxes into it. This pushes the liver forward and makes it easier to palpate with your right hand.
- Place your right hand on the right side of the patient’s abdomen.
- Place your fingertips at the lower border of the costal margin.
- Press gently inward and upward on the abdomen.
- Ask the patient to take a deep breath so you can feel the borders of the liver as it moves under your fingers.
- Ask the patient if they have any tenderness.
Try the Hooking method:
- This method is useful if you are unable to palpate the liver using the method above.
- Stand on the right side of the bed facing the foot of the bed.
- Use both hands and place them side by side at the costal margin.
- Press in and up toward the patients head with your finger. It is as if you are trying to hook your hands under the ribs.
- Have the patient take a deep breath.
- You should be able to feel the liver with both hands.
To palpate the spleen:
The spleen is not usually palpable except when enlarged.
- To palpate the spleen you can stand on the right side of the bed and reach over the patient.
- Place your left hand under the patients left side around the 11th or 12th rib.
- Have the patient relax their back on your hand.
- Lift the patient’s ribcage with your left hand.
- Palpate the spleen using the fingertips of the right hand.
- Place your hand just below the costal margin.
- Push your right hand inward and upward.
- Ask the patient to take a deep breath and see if you can feel the spleen with your fingertips.
- Ask the patient if they have any tenderness.
Tip #8 – How to Assess for Ascites
Ascites is usually seen in patients with cirrhosis of the liver. The patient will have a protuberant abdomen. Ascites is caused by a increased hydrostatic pressure in patients with cirrhosis of the liver. Percussion is normally used for the assessment of ascites, however, there are other methods. An abdomen with ascites will have both tympanic and dull sounds. You will hear tympany at the top of the abdomen around the epigastric area. And dullness will be heard lower around the umbilicus or any dependent areas of the abdomen.
Test for shifting dullness:
- This technique requires percussion.
- To begin you will need to map the areas of dullness and tympany using percussion.
- Then, have the patient turn onto their side.
- Percuss the areas you mapped again.
- If the person has ascites, the dull areas will shift or move to the more dependent side.
Test for a fluid wave:
- For this assessment technique, you will need help from an additional person.
- Have the additional person press both of their hand down on the middle of the abdomen. This keeps the wave from being transmitted through the fat in the abdomen.
- Place your hand on one side or the abdomen around the flank area and tap the other side with your fingertips sharply.
- You should feel the tapping in your hand on the opposite side as the impulse is transmitted through the fluid.
- This technique is not as accurate because you can feel this transmission of impulses in people without ascites.
Tip #9 – Assessing for Appendicitis
When a patient has appendicitis the pain usually begins at the umbilicus and radiates to the right lower quadrant. Sometimes coughing increases the pain.
Palpate for appendicitis:
- Have a patient cough to specify the area of pain.
- Also, light palpation can specify the area or tenderness.
- Use the fingertips to map the area of pain.
- The patient may guard if they have severe pain. The severe pain may turn into muscle rigidity.
- Check for rebound tenderness. Rebound tenderness usually indicates appendicitis.
Check for rebound tenderness: (Blumberg’s Sign)
- Once the area is mapped using palpation, press down with the fingers slowly.
- Next, withdraw your fingers quickly.
- Watch the patient for signs of pain.
- Ask the patient if it hurt more when you press down or when you let go.
- Have the patient point to where it hurts.
Rebound tenderness is present when there is pain with the withdrawal of the hand. The pain is caused by the movement of the peritoneum.
- A Rovsing’s sign is positive when pain is felt in the right lower quadrant when pressure is applied to the left lower quadrant of the abdomen.
- Referred rebound tenderness is when the patient has pain on the right side when pressure is applied to the left side of the abdomen and withdrawn quickly.
- Both of the signs indicate appendicitis.
- The psoas sign checks the iliopsoas muscle for irritation.
- Place the patient in a supine position.
- To perform the psoas sign, place your hand on the patient’s thigh just above the right knee.
- Have the patient raise their right leg against your hand.
- Push against the patients as they try to raise their leg.
- This test is positive if the patient feels pain.
- The pain is usually present in the right lower quadrant.
- This test is performed to assess the obturator muscle for irritation.
- Place the patient in a supine position.
- Flex the patient’s right leg at the hip while the knee is bent at a 90-degree angle.
- Grab the patient’s right knee and the right ankle and rotate the leg internally at the hip.
- This stretches the obturator muscle.
- If the patient has pain in the hypogastric or suprapubic area, this is a positive obturator sign.
- This test is done in the lower abdomen.
- Pick up a fold of skin between your fingers without squeezing.
- If the patient has pain this is indicative of appendicitis.
Check for an inflamed gallbladder
- The Murphy’s sign is found in patients that have an inflamed gallbladder.
- Place your fingers under the border of the liver.
- Have the patient take a deep breath.
- If the patient experiences pain and stops the respiration midway, this is a positive Murphy’s sign.
In conclusion, the tips above will help you with a nursing health assessment of the gastrointestinal system. Practice auscultation to distinguish the different bowel sounds. The skills of percussion and palpation take time to master. At first, the abdomen feels all the same. Also, review your anatomy and physiology and the article on 9 Facts about the gastrointestinal system every nursing student should know.
Bickley LS., Szilagyi PG., (2017). Bates Guide to Physical Examination and History Taking. 12th ed. Philadelphia, PA. Wolters Kluwer/Lippincott Williams & Wilkins.
Jarvis C., (2017). Physical Examination & Health Assessment. St Louis, MO. Elsevier Inc.
Mosby’s Medical Dictionary (2017). 10th ed. St Louis, MO. Elsevier Inc.
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