Part 1 Gastrointestinal

AssessmentIda Shepherd

Learning Outcomes

• Define some common terms• Identify and label structures of the

abdomen & anatomical landmarks• Begin to identify several organs within

each quadrant• Identify & demonstrate subjective &

objective data for assessment• Define what referred pain is• Label the viscera of the abdominal cavity

Terminology

• Abdominal Aortic Aneurysm

• Ascities

• Borborygmi

• Epigastrium

• Hernia

• Dyspepsia

• Pyrosis

• Striae

• Suprapubicv

• Viscera-solid vs hollow

• Involuntary rigidity

• Voluntary guarding

• Division of the abdomen for

Assessment

Right Upper Quadrant (RUQ)

Left Upper Quadrant (LUQ)

LiverGallbladderDuodenumHead of pancreasRight kidney and adrenalHepatic flexure of colonPart of ascending and transverse colon

StomachSpleenLeft lobe of liverBody of pancreasLeft kidney and adrenalSplenic flexure of colonPart of transverse and descending colon

Right Lower Quadrant (RLQ)

Left Lower Quadrant (LLQ)

CecumAppendixRight ovary and tubeRight ureterRight spermatic cord

Part of descending colonSigmoid colonLeft ovary and tubeLeft ureterLeft spermatic cordMidline

AortaUterus (if enlarged)

Bladder (if distended

Subjective Data1. Change in appetite2. Dysphagia3. Dyspepsia4. Food intolerance5. Abdominal pain6. Nausea/vomiting7. Change in bowel habits8. Rectal conditions9. Past abdominal history10. Medications11. History of alcohol, drug or cigarette use12. Nutritional assessment13. Family history of GI or renal cancer

Objective Data

Preparation:

• Empty bladder

• Warm room & equipment

• Supine

• Any painful areas

1. Inspect

2. Auscultate

3. Palpate

4. Percuss

Inspect

• Contour

• Symmetry

• Umbilicus

• Skin

• Veins

• Pulsation or movement

Auscultation

• Bowel Sounds

Palpation

• Only light palpation is used

• First four fingers close together, depressing eh skin about 1cm and making a gentle rotary motion, lifting the fingers and move clockwise

Percussion

• Percuss the abdomen using a clockwise sequence or up and down on the abdomen in each of the quadrants

Referred Abdominal Pain

• Absorption sites in the digestive tract.

• What does each segment absorb?

Case Scenario:

42 year old F presents to emergency with c/o RUQ pain and you are her nurse.

• Now what would you do?

Case StudyYou are asked by your charge nurse to evaluate a patient in the emergency room.

Patient is a 72-year-old male with history of hypertension, diabetes, and congestive heart failure who presents to the hospital with complaints of crampy diffuse abdominal pain and hematochezia. His medications include hydrochlorothiazide, digoxin, enalapril, metoprolol and glipizide. His past medical history is significant for benign prostatic hypertrophy, diabetic neuropathy, and osteoarthritis.

Physical exam revealed an elderly gentleman who appears in moderate distress secondary to his abdominal pain. On exam his pulse is 110/min, BP is 100/58, RR is 28, with a temperature of 37.7C. Abdomen is minimally distended, soft but mildly tender, without organomegaly, pulsatile mass, ecchymosis or free fluid. The rest of his physical examination was within normal limits. Rectal exam reveals a diffusely large prostate with guiac (occult) positive stool.

A CT scan of the abdomen was ordered in the emergency room that revealed thickened sigmoid colon with some pericolonic stranding suggestive of ischemic colitis.

Case Study: True story• A 72-year-old man with no prior medical history presents for

evaluation of lower abdominal pain for the prior 24 hours. He has no history of fever, chills, or other symptoms. Vital signs are stable. On physical exam, the patient has minor lower abdominal pain but no guarding or rebound tenderness. Rectal examination shows mild prostatic tenderness on palpation. The remainder of the examination is normal. Lab tests showed a WBC count of 10.8, urinalysis had 5-10 WBCs but no bacteria. The patient was diagnosed with prostatitis and discharged with a prescription for ciprofloxacin.

• The epilogue to this case was that the patient returned 10 days later with worsening abdominal pain. A CT scan performed on the return visit showed that he had ruptured his appendix, cecum, and ileum. During surgery, the patient required a permanent ileostomy. He suffered a prolonged postoperative course in the ICU. The case settled for $350,000 before trial.

References

Jarvis, C. (2012). Jarvis’s physical examination & health assessment. (Australian and New Zealand edition). Sydney, Australia: Saunders Elsevier.

Jarvis, C. (2012). Jarvis’s physical examination & health assessment. (Australian and New Zealand edition). Pocket companion. Sydney, Australia: Saunders Elsevier

Part 2 Nutritional Assessment of the Older Adult

• Readings: Lewis, Chapter 38,39, “GI” & “Nutrition” (3rd ed) (2012)

• Lewis Chapter 34 & 35 “GI” & “Nutrition” (4th ed) (2015)

• Skim Crisp & Taylor, Chapter 43, “Nutrition”

• Assorted Moodle Documents

Learning Outcomes

1. Differentiate between the social, cultural, and emotional aspects of food and the

physiologic aspects of nutrients and food.   2.    Correlate the physiologic changes of aging with food intake patterns.   3.    Differentiate between a nutritional screen and a nutritional assessment.   4.    Identify assorted nutritional assessment templates and competently complete at least

one.   5.    Identify the steps and core data collection elements for a nutritional assessment.   6.    Describe the changes in nutritional requirements for aging persons.   7.    Distinguish between enteral and parenteral intake.

8. Describe the role of therapeutic diets and nutritional support in nutritional therapies.

The meaning of food

• Different for everyone

• Encompasses many things:

• History of food

• Cultural aspects of food

• Religious aspects of food

• Food and our emotions

What is the importance of reviewing nutritional status in the OA?

• Physiological Health

• Psychological Health

• Social Health

• Spiritual Health

Review of:

• Carbohydrates

• Fats

• Proteins

• Vitamins

• Minerals

Malnutrition : A vicious circle Malnutrition

Reduced Feeding Capabilities Apathy depression

Poor concentration

Reduced mobility

Poor appetite

Loss of muscle

strength This diagram can apply to any malnourished patient.

Aging & Malnutrition

Why is this an issue?

Changes with aging:• Physical

• diminishing eye sight

• poor dentition

• taste changes

• poor swallowing

• Physiological

• Metabolic

• Psychosocial changes

• Refer to chapter 5, table 5-5 “Older Adults in Lewis 3rd ed (2012)

Factors Affecting Food Choice:

1. Adequate income to purchase food

2. Educational level

3. Nutrition knowledge

4. Ability to read food labels & interpret information

5. Food allergies and intolerances

6. Problems with chewing and swallowing

7. Loss of spouse

8. Disease or pathological process

9. Ability to access shops

10.Religious and cultural dietary practicesBox 43-6 Focus on older adultsCrisp & Taylor, Chapter 43, p. 1143

Factors affecting nutrient absorption• Alcohol consumption

• Decreased liver, renal, GI, pancreatic function

• Decreased HCL & digestive enzymes

• GI malabsorption

• Polypharmacy/chronic medication

• Disease & pathology

• Factors affecting nutrient absorption:

• See: Box 43-6 Focus on older adultsCrisp & Taylor, Chapter 43, p. 1143

• Identify & rule out contributing causes of nutrition & hydration problems

• Environmental issues

• Food preferences – food & fluid of choice

• Dentition & oral health

• Dysphagia/SLT referral

• Mental health – depression?

• Faecal impaction

• Infection / UTI/URT/GI

• Decline in ADL/mobility

• Requires increased assistance

• Medication – iatrogenic causes

• Underlying pathology

• GI disturbance

Functional impairments making nutritional intake difficult or impossible (F.I.M -Lecture 1).

IADL’s

Ability to use telephone

Shopping

Food preparation

Housekeeping

Laundry

Transportation

Medication use

Ability to handle finances

ADL’s

Bathing

Dressing

Grooming/toileting

Eating

Continence

Transferring

Undernutrition in the elderly

Malnourished elderly are:2 times more likely to visit the doctor3 times more likely to be hospitalized

Infection is the most common disorder2 - 10 times more likely to die if malnourished

Diminished muscle strength Poor healingMalnutrition is a greater threat than obesityAnthony (2006)

What is the difference between a nutritional screening and a nutritional assessment?

•A nutritional screening is an abridged assessment to quickly identify individuals at risk for malnutrition or are malnourished. •A nutritional assessment is a comprehensive evaluation of a client’s nutritional status to identify early signs of malnutrition and prevent the condition from becoming a co-morbidity or cause of mortality.

A nutritional assessment must include:

1.Demographics

2.Psychosocial data

3.Medical history

4.Dietary history

5.Anthropometrics

6.Medications

7.Lab values

8.Physical assessment

Screening Tools

Mini Nutritional Assessment (MNA)

S

C

A

L

E

S

BMI: 18.5 & 24.9 kg/m² = normal weightBMI: 25-29.9 kg/m² overweightBMI: 30 kg/m² + obeseBMI: 40 kg/m² + morbidly obeseCalculate your BMI

Why do older people need more of some nutrients than younger adults:

More nutrients

Smaller portions

Enteral Parenteral

Enteral vs Parenteral Nutrition

• Enteral Nutrition

• – AKA Tube Feeding

• – Thru the GI tract

• – More physiological

• – Uses the gut

• – More convenient

• – Less risky

• – Less costly

 

• Parenteral Nutrition

• – AKA TPN, Hyperal

• – Thru a central vein, IV

• – Less physiological

• – Gives the gut a rest

• – Less convenient

• – More risk ie: infection

• – More costly

Parenteral Enteral

Enteral Key Points1. Preferred form of non-oral feeding (gavage)

2. Types of enteral feeding

3. Aspiration pneumonia d/t reflux

4. HOB elevation & length of time post-feed

5. Expiry of feed

6. Paralytic ileus

7. Temperature of feed

8. Flushing of tube

See Box 39-7“Nursing Management: Feeding Tubes in Lewis, Chapter 39, p. 1040. (3rd ed)

PARENTERAL KEY POINTS:

• Used when the GI tract cannot be used for the ingestion, digestion and absorption of essential nutrients.

• Hypertonic solution consisting of glucose, proteins, minerals and vitamins.

• Solutions are customized for the patient.

• Advanced nursing skill as there are more serious complications that can occur with parenteral rather than enteral nutrition.

• Clinical & lab monitoring of patient status.

• How many therapeutic diets can you think of?

• What kinds of therapeutic diets can you come up with?

Example of common hospital diets:1. Full liquid

2. Soft

3. Bland

4. Low residue/low fibre

5. High residue/high fibre

6. Fat controlled – low fat

7. High calorie

8. Sodium restricted – low sodium

9. Protein restricted –renal diet

10.High protein

11.Clear liquid

12.Low calcium

13.High calcium

14.Low purine

15.High iron

16.Diverticular diet

17.Fluid restriction

18.Carbohydrate controlled – diabetic or calorie restricted

19.Non-allergy diet

Failure to Thrive&

Frailty

FAILURE TO THRIVE

• Is a common term used with babies.

• Sarkisian and Lachs (1996) used it to describe what was happening to OA.

• Multi-dimensional but most quoted are:

Impaired physical functioning

Malnutrition

Depression

Cognitive impairment

FRAILTY

• Mostly afflicts the old-old (85+ most at risk)

• Frailty is a strong predictor of several negative outcomes including disabilities, institutionalisation, and mortality and has also been linked to acute illness, falls, and increased vulnerability (Benefield, 2007).

• Caring for frail older adults is difficult and challenging because they have an increased burden of symptoms, are medically complex, and often have increased social needs (Espinoza & Walston in Benefield, 2007)

According to the Cardiovascular Health Study Fried, Tangen, Walston et al (2001) in Espinoza & Walston, (2005)

A frail person must have 3/5 of the following:

Slow walking speed

Poor hand grip

Exhaustion

Weight loss

Low energy expenditure

References

• Benefield, L.E. (2007

• Brown, D., & Edwards, H. (2011)

• Crisp, J., & Taylor C. (2009)

• Espinoza, S., & Walston, J. D. (2005)

• Meiner, S.E., & Leuckenotte, A.G. (2006)

SCENARIO:

A 71-year-old man is a Seventh Day Adventist and practices vegetarianism. He does not eat fish, but he does eat eggs. His physician has recommended that he ingest more protein.

• Question:

• What recommendations can the nurse offer?

SCENARIO:

• Sam Lang is a 62-year-old who sustained a closed head injury 3 days ago. He remains unconscious. Sam is to be started on enteral tube feeds. What are the potential complications of enteral tube feeding and the nursing interventions to minimise the occurrence of these?

• Work out on your own.

Nutrition and the Older Adult Nutrition Assessment MCQ:

1. Spironolactone (Aldactone), a diuretic, is prescribed for a client with congestive heart failure. A nurse provides dietary instructions to the client and instructs the client to avoid foods that are high in which electrolyte?

A. CalciumB. PotassiumC. MagnesiumD. Phosphorus

2. A client who is recovering from gastric surgery has been advanced from a clear liquid diet to a full liquid diet. The client is looking forward to the diet change because he has been “bored” with the clear liquid diet.

The nurse would most appropriately offer which full liquid item to the client?A. GelatinB. Chocolate puddingC. Black coffeeD. Fruit ice block