NURSING ASSESSMENT:

Chapter 35

Gastrointestinal system
Written by Paula Cox-North
Adapted by Marie Verschoor

LEARNING OUTCOMES KEY TERMS

1. Describe the structure and function of the organs of the gastrointestinal tract. bilirubin, p 882
2. Describe the structure and function of the liver, gall bladder, biliary tract and borborygmi, p 888
pancreas. cheilosis, Table 35-9, p 890
3. Explain the processes of ingestion, digestion, absorption and elimination. deglutition, p 877
4. Explain the processes of biliary metabolism, bile production and bile excretion. endoscopy, p 896
haematemesis, Table 35-9, p 890
5. Link the age-related changes of the gastrointestinal system to differences in hepatocytes, p 880
assessment findings.
Kupffer cells, p 880
6. Select significant subjective and objective assessment data related to the melaena, Table 35-9, p 891
gastrointestinal system that should be obtained from a patient. pyorrhoea, Table 35-9, p 890
7. Identify the appropriate techniques used in the physical assessment of the pyrosis, Table 35-9, p 890
gastrointestinal system. steatorrhoea, Table 35-9, p 891
8. Differentiate between the normal and abnormal findings of a physical assessment of tenesmus, Table 35-9, p 891
the gastrointestinal system. Valsalva manoeuvre, p 880
9. Describe the purpose, significance of results, and nursing responsibilities related to
diagnostic studies of the gastrointestinal system.

Structures and functions of the For example, peristalsis is increased by parasympathetic

stimulation and decreased by sympathetic stimulation.
gastrointestinal system Sensory information is relayed via both sympathetic and
The gastrointestinal (GI) system (also called the digestive parasympathetic afferent fibres.
system) consists of the GI tract and its associated organs and The GI tract has its own nervous system: the enteric (or
glands. Included in the GI tract are the mouth, oesophagus, intrinsic) nervous system. The enteric nervous system is
stomach, small intestine, large intestine, rectum and anus. composed of two nerve layers that lie between the mucosa and
The associated organs are the liver, pancreas and gall bladder the muscle layers. These neurons have receptors for pressure
(Fig 35-1). and movement.
Factors outside the GI tract can influence its functioning. The GI tract and accessory organs receive approximately
Both psychological and emotional factors, such as stress and 25% to 30% of the cardiac output at rest and 35% or more
anxiety, influence GI functioning in many people. Stress after eating. Circulation in the GI system is unique in that
may be manifested as anorexia, epigastric and abdominal venous blood draining the GI tract organs empties into the
pain, or diarrhoea or constipation. However, GI problems portal vein, which then perfuses the liver. The vascular supply
should never be attributed solely to psychological factors. to the GI tract includes the coeliac artery, superior mesenteric
Organic- and psychologically-based problems can exist artery (SMA) and inferior mesenteric artery (IMA). The
independently or concurrently. Physical factors, such as stomach and duodenum receive their blood supply from
dietary intake, ingestion of alcohol and caffeine-containing the coeliac axis. The distal small intestine to the mid large
products, cigarette smoking, poor sleep, fatigue, mobility and intestine receives its blood supply from branches of the hepatic
exercise, may also affect GI function. Some organic diseases and superior mesenteric arteries. The distal large intestine
of the GI system, such as peptic ulcer disease and ulcerative through to the anus receives its blood supply from the IMA.
colitis, may be aggravated by stress. Because such a large percentage of the cardiac output perfuses
The GI tract extends approximately 9 metres from the these organs, the GI tract is a major source from which blood
mouth to the anus. It is composed of four common layers. flow can be diverted during exercise, stress or injury.
From the inside to the outside, these layers are: (1) mucosa, The abdominal organs are almost completely covered
(2) sub­mucosa, (3) muscle, and (4) serosa. The muscular by the peritoneum. The two layers of the peritoneum are the
coat consists of two layers: the circular (inner) layer and the parietal layer, which lines the abdominal cavity wall, and
longitudinal (outer) layer. the visceral layer, which covers the abdominal organs. The
The GI tract is innervated by the parasympathetic and peritoneal cavity is the potential space between the parietal
sympathetic branches of the autonomic nervous system. The and visceral layers. The two folds of the peritoneum are the
parasympathetic (cholinergic) system is mainly excitatory, mesentery and the omentum. The mesentery attaches the
and the sympathetic (adrenergic) system is mainly inhibitory. small intestine and part of the large intestine to the posterior

876
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 Chapter 35  Nursing Assessment: Gastrointestinal system 877

Parotid
gland

Submandibular Tongue
gland
Sublingual gland
Pharynx
Larynx Hepatic
Trachea bile duct
Liver
Oesophagus Cystic
duct

Diaphragm Gall bladder

Duodenum
Liver Spleen
Pancreas
Hepatic
flexure Spleen
Transverse Splenic flexure
colon Stomach
Ascending
Descending colon
colon
Ileum
Caecum
Sigmoid colon
Region of
Rectum
ileocaecal
valve Anal canal
Vermiform
appendix

Figure 35-1  Location of organs of the gastrointestinal system.

Source: Thibodeau & Patton, 1999.

abdominal wall and contains blood and lymph vessels. The Mouth
omentum hangs like an apron from the stomach to the intestines The mouth consists of the lips and the oral (buccal) cavity.
and contains fat and lymph nodes. The lips surround the orifice of the mouth and function in
The main function of the GI system is to supply nutrients speech. The roof of the oral cavity is formed by the hard
to body cells. This is accomplished through the processes of: and soft palates. The oral cavity contains the teeth, used in
(1) ingestion (taking in food), (2) digestion (breaking down mastication (chewing), and the tongue. The tongue is a solid
food), and (3) absorption (transferring food products into muscle mass and assists in chewing and moving food to the
circulation). Elimination is the process of excreting the waste back of the throat for swallowing. Taste receptors (taste buds)
products of digestion. Each part of the GI system performs are found on the sides and tip of the tongue. The tongue is
different activities to accomplish these functions. also important in speech.
Within the oral cavity are three pairs of salivary glands:
INGESTION the parotid, submaxillary and sublingual glands. These glands
Ingestion is the intake of food. A person’s appetite or desire produce saliva, which consists of water, protein, mucin, inorganic
to ingest food influences how much food is eaten. An appetite salts and salivary amylase.
centre is located in the hypothalamus. It is directly or indirectly
stimulated by hypoglycaemia, an empty stomach, decrease in Pharynx
body temperature, and input from higher brain centres. The The pharynx is a musculomembranous tube that is divided
hormone ghrelin released from the stomach mucosa plays a into the nasopharynx, the oropharynx and the laryngeal
role in appetite stimulation. Another hormone, leptin, is involved pharynx. The mucous membrane of the pharynx is continuous
in appetite suppression. (Ghrelin and leptin are discussed in with the nasal cavity, mouth, auditory tubes and larynx.
Ch 37.) The sight, smell and taste of food frequently stimulate The epiglottis is a lid of fibrocartilage that closes over the
appetite. Appetite may be inhibited by stomach distension, larynx during swallowing. During ingestion, the oropharynx
illness (especially accompanied by fever), hyperglycaemia, provides a route for food from the mouth to the oesophagus.
nausea and vomiting, and certain drugs (e.g. amphetamines). When receptors in the oropharynx are stimulated by food or
Deglutition (swallowing) is the mechanical component of liquid, the swallowing reflex is initiated. The tonsils and the
ingestion. The organs involved in the deglutition of food are adenoids, composed of lymphoid tissue, assist the body in
the mouth, the pharynx and the oesophagus. preventing infection.

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 878 Section 8  Problems of ingestion, digestion, absorption and elimination

Oesophagus The serous (outer) layer of the stomach is formed by the

The oesophagus is a hollow, muscular tube that receives food peritoneum. The muscular layer consists of the longitudinal
from the pharynx and moves it to the stomach. It is 18 to 25 cm (outer) layer, the circular (middle) layer and the oblique (inner)
long and 2 cm in diameter. The oesophagus is located in the layer. The mucosal layer forms folds called rugae that contain
thoracic cavity. The upper third of the oesophagus is composed many small glands. In the fundus the glands contain chief cells,
of striated skeletal muscle, and the distal two thirds are composed which secrete pepsinogen, and parietal cells, which secrete
of smooth muscle. hydrochloric acid (HCl), water and intrinsic factor. The secretion
With swallowing, the upper oesophageal sphincter (crico­ of HCl makes gastric juice acidic. This acidic pH aids in the
pharyngeal muscle) relaxes and a peristaltic wave moves the protection against ingested organisms. Intrinsic factor promotes
bolus into the oesophagus. Between swallows, the oesophagus vitamin B12 absorption in the small intestine.
is collapsed. It is structurally composed of four layers: inner
mucosa, submucosa, muscularis propria and outermost Small intestine
adventitia. The two primary functions of the small intestine are digestion
The muscular layers contract (peristalsis) and propel the and absorption (uptake of nutrients from the gut lumen to the
food to the stomach. There are two sphincters: the upper bloodstream). The small intestine is a coiled tube approximately
oesophageal sphincter (UES) at the proximal end of the 7 m in length and 2.5 to 2.8 cm in diameter. It extends from the
oesophagus and the lower oesophageal sphincter (LES) at pylorus to the ileocaecal valve. The small intestine is composed
the distal end. The LES remains contracted except during of the duodenum, jejunum and ileum. The ileocaecal valve
swallowing, belching or vomiting. The LES is an important prevents reflux of large intestine contents into the small intestine.
barrier that normally prevents reflux of acidic gastric contents The mucosa of the small intestine is thick, vascular and
into the oesophagus. glandular. The functional units of the small intestine are villi,
minute, finger-like projections in the mucous membrane. They
DIGESTION AND ABSORPTION contain epithelial cells that produce the intestinal digestive
enzymes. The epithelial cells on the villi also have microvilli.
Stomach
The circular folds in the mucous and submucous layers, along
The stomach’s functions are to store food, mix food with gastric
with the villi and microvilli, increase the surface area for
secretions, and empty contents in small boluses into the small
digestion and absorption.
intestine. The stomach absorbs only small amounts of water,
The digestive enzymes on the brush border of the microvilli
alcohol, electrolytes and certain drugs.
chemically break down nutrients for absorption. The villi
The stomach is usually J shaped and lies obliquely in the
are surrounded by the crypts of Lieberkühn, which contain
epigastric, umbilical and left hypochondriac regions of the
the multipotent stem cells for the other epithelial cell types.
abdomen (see Fig 35-8 later in the chapter). It always contains
(Stem cells are discussed in Ch 9.) Brunner’s glands in the
gastric fluid and mucus. The three main parts of the stomach
submucosa of the duodenum secrete an alkaline fluid con­
are the fundus (cardia), the body and the antrum (Fig 35-2). The
tain­ing bicarbonate. Intestinal goblet cells secrete mucus that
pylorus is a small portion of the antrum proximal to the pyloric
protects the mucosa.
sphincter. Sphincter muscles (the LES and the pyloric sphincter)
guard the entrance to and exit from the stomach. Physiology of digestion
Digestion is the physical and chemical breakdown of food into
absorbable substances. Digestion in the GI tract is facilitated by
Lower oesophageal the timely movement of food through the tract and the secretion
sphincter of specific enzymes. These enzymes break down foodstuffs to
Longitudinal
muscle layer Fundus particles of appropriate size for absorption (Table 35-1).
Circular
The process of digestion begins in the mouth, where the
Muscularis food is chewed, mechanically broken down, and mixed with
muscle layer
Oblique saliva. Approximately 1 L of saliva is produced each day. Saliva
muscle layer facilitates swallowing by lubricating food. Saliva contains
Mucosa
amylase (ptyalin), which breaks down starches to maltose.
Submucosa Salivary gland secretion is stimulated by chewing movements
Body and the sight, smell, thought and taste of food. After swallow­
Duodenal
bulb Pyloric ing, food is moved through the oesophagus to the stomach. No
sphincter digestion or absorption occurs in the oesophagus.
re

a In the stomach the digestion of proteins begins with the

tu

Lesser cur v release of pepsinogen from chief cells. The stomach’s acidic
environment results in the conversion of pepsinogen to its
active form, pepsin. Pepsin begins the breakdown of proteins.
Serosa There is minimal digestion of starches and fats in the stomach.
The food is mixed with gastric secretions, which are under neural
tur
e and hormonal control (Tables 35-2 and 35-3). The stomach also
u r va serves as a reservoir for food, which is slowly released into
Duodenum c
Greater the small intestine. The length of time that food remains in the
Antrum
Pylorus Rugae stomach depends on the composition of the food, but average
meals remain from 3 to 4 hours. Figure 35-3 shows the different
Figure 35-2  Parts of the stomach. absorption sites in the digestive tract.

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 Chapter 35  Nursing Assessment: Gastrointestinal system 879

In the small intestine, carbohydrates are broken down nature of chyme (food mixed with gastric secretions) stimulate
to monosaccharides, fats to glycerol and fatty acids, and motility and secretion. Secretions involved in digestion include
proteins to amino acids. The physical presence and chemical enzymes from the pancreas, bile from the liver (see Table 35-1),
and enzymes from the small intestine. Enzymes on the brush
border of the microvilli complete the digestion process. These
TABLE 35-1  Gastrointestinal secretions enzymes break down disaccharides to monosaccharides and
peptides to amino acids for absorption.
Daily Secretions,
amount (mL) enzymes Action
Both secretion and motility are under neural and hormonal
control. When food enters the stomach and small intestine,
Salivary glands hormones are released into the bloodstream (see Table 35-3).
1000–1500 Salivary amylase Initiation of starch digestion These hormones play important roles in the control of HCl
(ptyalin) secretion, production and release of digestive enzymes, and
Stomach motility.
Absorption is the transfer of the end products of digestion
2500 Pepsinogen Protein digestion across the intestinal wall to the circulation. Most absorption
HCl Activation of pepsinogen to occurs in the small intestine (Fig 35-3). The movement of the villi
pepsin enables the end products of digestion to come in contact with the
Lipase Fat digestion absorbing membrane. Monosaccharides (from carbohydrates),
fatty acids (from fats), amino acids (from proteins), water,
Intrinsic factor Essential for Vitamin B12
electrolytes, vitamins and minerals are absorbed.
absorption in ileum
Small intestine ELIMINATION
3000 Enterokinase Activation of trypsinogen to Large intestine
trypsin The large intestine is a hollow, muscular tube approximately
Amylase Carbohydrate digestion 1.5 to 1.8 m long and 5 cm in diameter. The four parts of the
Peptidases Protein digestion large intestine are shown in Figure 35-4.
Aminopeptidases Protein digestion
TABLE 35-2  Phases of gastric secretion
Maltase Maltose to two glucose
molecules Stimulus to secretion Secretion
Sucrase Sucrose to glucose and Cephalic (nervous)
fructose Sight, smell, taste of food HCl, pepsinogen, mucus
Lactase Lactose to glucose and (before food enters stomach).
galactose Initiated in the CNS and
mediated by the vagus nerve.
Lipase Fat digestion
Gastric (hormonal and nervous)
Pancreas
Food in antrum of stomach, Release of gastrin from antrum
700 Trypsinogen Protein digestion vagal stimulation. into circulation to stimulate
Chymotrypsin Protein digestion gastric secretions and motility

Amylase Starch to disaccharides Intestinal (hormonal)

Lipase Fat digestion Presence of chyme in small Acidic chyme (pH <2): Release of
intestine. secretin, gastric inhibitory
Liver and gall bladder polypeptide, cholecystokinin
into circulation to decrease
1000 Bile Emulsification of fats and aid in
HCl secretion
absorption of fatty acids and
Chyme (pH >3): Release of
fat-soluble vitamins (A, D, E, K)
gastrin from duodenum to
HCl, hydrochloric acid. increase acid secretion

TABLE 35-3  Hormones controlling GI secretion and motility

Hormone Source Activating stimuli Function
Gastrin Gastric and Stomach distension, partially Stimulates gastric acid secretion and motility. Maintains
duodenal mucosa digested proteins in pylorus lower oesophageal sphincter tone.
Secretin Duodenal mucosa Acid entering small intestine Inhibits gastric motility and acid secretion. Stimulates
pancreatic bicarbonate secretion.
Cholecystokinin Duodenal mucosa Fatty acids and amino acids in Contracts gall bladder and relaxes sphincter of Oddi.
small intestine Allows increased flow of bile into duodenum; release of
pancreatic digestive enzymes.
Gastric inhibitory Duodenal mucosa Fatty acids and lipids in small Inhibits gastric acid secretion and motility.
peptide intestine

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 880 Section 8  Problems of ingestion, digestion, absorption and elimination

Defecation is a reflex action involving voluntary and

involuntary control. Faeces in the rectum stimulate sensory
nerve endings that produce the desire to defecate. The reflex
STOMACH centre for defecation is in the sacral portion of the spinal
cord (parasympathetic nerve fibres). These fibres produce
contraction of the rectum and relaxation of the internal anal
Alcohol sphincter. Defecation is controlled voluntarily by relaxing the
(20% of total) external anal sphincter when the desire to defecate is felt. An
SMALL INTESTINE acceptable environment for defecation is usually necessary, or
the urge to defecate will be ignored. If defecation is suppressed
Calcium, magnesium, over long periods, problems can occur, such as constipation or
Glucose iron faecal impaction.
Fat-soluble Defecation can be facilitated by the Valsalva manoeuvre.
Water-soluble vitamins This manoeuvre involves contraction of the chest muscles
vitamins on a closed glottis with simultaneous contraction of the
Amino acids
Alcohol abdominal muscles. These actions result in increased
(80% of total) Fats intra­abdominal pressure. The Valsalva manoeuvre may be
Sodium, potassium contraindicated in the patient with a head injury, eye surgery,
Water 90%
cardiac problems, haemorrhoids, abdominal surgery, or liver
cirrhosis with portal hypertension.
Vitamin B12 Bile
LIVER, BILIARY TRACT AND PANCREAS
COLON Liver
Sodium, potassium The liver is the largest internal organ in the body, weighing
approximately 1.36 kg. It lies in the right epigastric region
(Fig 35-5). Most of the liver is enclosed in peritoneum. It has
Water 9% a fibrous capsule that divides it into right and left lobes.
Acids and bases The functional units of the liver are lobules (see Fig 35-6).
The lobule consists of rows of hepatic cells (hepatocytes)
arranged around a central vein. The capillaries (sinusoids) are
RECTUM located between the rows of hepatocytes and are lined with
Kupffer cells, which carry out phagocytic activity (removal of
bacteria and toxins from the blood). Interlobular bile ducts form
from bile capillaries (canaliculi). The hepatic cells secrete bile
into the canaliculi.
Faeces About one quarter of the blood supply comes from the
hepatic artery (branch of the coeliac artery), and three quarters
Figure 35-3  Absorption sites in the digestive tract. comes from the portal vein. The portal circulatory system
Source: Patton & Thibodeau, 2010. (enterohepatic) brings blood to the liver from the stomach, the
intestines, the spleen and the pancreas. The portal vein carries
absorbed products of digestion directly to the liver. In the liver
The most important function of the large intestine is the the portal vein branches and comes in contact with each lobule.
absorption of water and electrolytes. The large intestine also The liver is essential for life. It functions in the manufacture,
forms faeces and serves as a reservoir for the faecal mass storage, transformation and excretion of a number of substances
until defecation occurs. Faeces are composed of water (75%), involved in metabolism. The liver’s functions are numerous and
bacteria, unabsorbed minerals, undigested foodstuffs, bile can be classified into four main areas (Table 35-4).
pigments and desquamated (shed) epithelial cells. The large
intestine secretes mucus, which acts as a lubricant and protects Biliary tract
the mucosa. The biliary tract consists of the gall bladder and the duct
Microorganisms in the colon are responsible for the system. The gall bladder is a pear-shaped sac located below
breakdown of proteins not digested or absorbed in the small the liver. The gall bladder’s function is to concentrate and store
intestine. These amino acids are deaminated by the bacteria, bile. It holds approximately 45 mL of bile.
leaving ammonia, which is carried to the liver and converted Bile is produced by the hepatic cells and secreted into
to urea, which is excreted by the kidneys. Bacteria in the colon the biliary canaliculi of the lobules. Bile then drains into the
also synthesise vitamin K and some of the B vitamins. Bacteria interlobular bile ducts, which unite into the two main left and
also play a part in the production of flatus. right hepatic ducts. The hepatic ducts merge with the cystic
The movements of the large intestine are usually slow. duct from the gall bladder to form the common bile duct (see
However, propulsive (mass movements) peristalsis also Fig 35-5). Most of the bile is stored and concentrated in the gall
occurs. When food enters the stomach and duodenum, gastro­ bladder. It is then released into the cystic duct and moves down
colic and duodenocolic reflexes are initiated, resulting in the common bile duct to enter the duodenum at the ampulla of
peristalsis in the colon. These reflexes are more active after Vater. In the intestines, bilirubin is reduced to stercobilinogen
the first daily meal and frequently result in bowel evacuation. and urobilinogen by bacterial action. Stercobilinogen accounts

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 Chapter 35  Nursing Assessment: Gastrointestinal system 881

Splenic (left colic)

flexure
Transverse
colon
Inferior vena
cava
Aorta Splenic vein
Hepatic
(right colic)
flexure Superior
mesenteric
artery

Ascending
Descending colon
colon
Right colic
artery

Inferior
Mesentery mesenteric
artery
and vein
Ilium
Sigmoid
artery and
Ileocaecal
vein
valve

Caecum Sigmoid colon

Ileum

Vermiform
appendix
Rectum
Superior rectal
artery and vein

Figure 35-4  Anatomical locations of the large intestine.

Source: Patton & Thibodeau, 2013.

Right hepatic duct Left hepatic duct Common

Liver plate Central vein
hepatic duct

Sublobular
Common vein
bile duct

Pancreas (body)
Sinusoids

Pancreas (tail) Bile canaliculus

Gall bladder Kupffer cells
Cystic duct Lymph channel
Ampulla of Vater
Hepatic artery Bile duct
Pancreas (head) Duodenum
Main pancreatic duct Portal vein branch

Figure 35-5  Gross structure of the liver, gall bladder, pancreas Figure 35-6  Microscopic structure of a liver lobule.
and duct system.

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 882 Section 8  Problems of ingestion, digestion, absorption and elimination

Blood cells
TABLE 35-4  Functions of the liver RBC (destruction by macrophage system)
Function Description
Metabolic functions
Carbohydrate Glycogenesis (conversion of glucose to glycogen), Haemoglobin
metabolism glycogenolysis (process of breaking down
glycogen to glucose), gluconeogenesis (formation
of glucose from amino acids and fatty acids). Unconjugated bilirubin

Protein Synthesis of non-essential amino acids, synthesis Insoluble so attached to albumin

metabolism of plasma proteins (except gamma-globulin),
synthesis of clotting factors, urea formation from Liver Unconjugated bilirubin
ammonia (NH3) (NH3 formed from deamination of combines with glucuronic
amino acids by action of bacteria in colon). acid to become conjugated
Fat Synthesis of lipoproteins, breakdown of bilirubin (soluble)
metabolism triglycerides into fatty acids and glycerol,
formation of ketone bodies, synthesis of fatty
acids from amino acids and glucose, synthesis and Small amount
breakdown of cholesterol. of urobilinogen
Excreted in bile goes via systemic
Detoxification Inactivation of drugs and harmful substances and
circulation to kidneys
excretion of their breakdown products. and excreted
Steroid Conjugation and excretion of gonadal and adrenal in urine
metabolism corticosteroid hormones. Intestines
Bilirubin reduced
Bile synthesis to urobilinogen
by intestinal
Bile Formation of bile, containing bile salts, bile Recycled in bacteria
production pigments (mainly bilirubin) and cholesterol. bile; travels
to liver via portal Kidney
Bile excretion Bile excretion by liver about 1 L/day. (enterohepatic)
circulation
Storage Glucose in form of glycogen. Vitamins, including
fat soluble (A, D, E, K) and water soluble (B1, B2, B12, Urine
folic acid). Fatty acids. Minerals (iron, copper). Stool
Amino acids in form of albumin and beta-
globulins. Figure 35-7  Bilirubin metabolism and conjugation.
Mononuclear phagocyte system
Kupffer cells Breakdown of old RBCs, WBCs, bacteria and other
particles. Breakdown of haemoglobin from old
RBCs to bilirubin and biliverdin. The pancreas has both exocrine and endocrine functions.
RBCs, red blood cells; WBCs, white blood cells. The exocrine function contributes to digestion through the
production and release of enzymes (see Table 35-1). The
endocrine function occurs in the islets of Langerhans, whose
β cells secrete insulin and amylin; α cells secrete glucagon;
δ cells secrete somatostatin; and F cells secrete pancreatic
for the brown colour of stool. A small amount of conjugated polypeptide.
bilirubin is reabsorbed into the blood. Some urobilinogen is
reabsorbed into the blood, returned to the liver through the
portal circulation (enterohepatic), and excreted in the bile.
Assessment of the gastrointestinal
system
Bilirubin metabolism
SUBJECTIVE DATA
Bilirubin, a pigment derived from the breakdown of haemoglobin,
is constantly produced (Fig 35-7). Because it is insoluble in Important health information
water, it is bound to albumin for transport to the liver. This form Past health history
of bilirubin is referred to as unconjugated. In the liver, bilirubin Gather information from the patient about the history or
is conjugated with glucuronic acid. Conjugated bilirubin is existence of the following problems related to GI functioning:
soluble and is excreted in bile. Bile also consists of water, abdominal pain, nausea and vomiting, diarrhoea, constipation,
cholesterol, bile salts, electrolytes and phospholipids. Bile salts abdominal distension, jaundice, anaemia, heartburn, dyspepsia,
are needed for fat emulsification and digestion. changes in appetite, haematemesis, food intolerance or allergies,
indigestion, excessive gas, bloating, lactose intolerance,
Pancreas melaena, trouble swallowing, haemorrhoids or rectal bleeding.
The pancreas is a long, slender gland lying behind the stomach In addition, ask the patient about a history or existence of
and in front of the first and second lumbar vertebrae. It consists diseases such as reflux, gastritis, hepatitis, colitis, gallstones,
of a head, body and tail. The anterior surface of the pancreas peptic ulcer, cancer, diverticuli or hernias.
is covered by peritoneum. The pancreas contains lobes and As part of the physical examination, question the patient
lobules. The pancreatic duct extends along the gland and enters about weight history. Explore in detail any unexplained or
the duodenum through the common bile duct (Fig 35-5). unplanned weight loss or gain within the past 6 to 12 months.

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 Chapter 35  Nursing Assessment: Gastrointestinal system 883

Gerontological considerations: Effects of ageing on the gastrointestinal system

The process of ageing changes the functional ability of the GI system constipation include slower peristalsis, inactivity, decreased dietary
(Table 35-5). Diet, alcohol intake and obesity affect organs of the GI fibre, decreased fluid intake, constipating medications and laxative
system, making it a challenge to separate the sole effects of ageing abuse; neurological, cognitive and metabolic disorders may also play
from lifestyle. Xerostomia (decreased saliva production), or dry mouth, a role.4,5 (Constipation is discussed in Ch 39.)
affects many older adults and may be associated with difficulty The liver size decreases after 50 years of age, but results of liver
swallowing (dysphagia).1 Many factors can lead to a decrease in function tests remain within normal ranges. Age-related enzyme
appetite and make eating less pleasurable. These include a decrease changes in the liver decrease the liver’s ability to metabolise drugs
in taste buds and salivary gland secretion, diminished sense of smell, and hormones.
and caries and periodontal disease leading to loss of teeth. The size of the pancreas is unaffected by ageing, but it does
Age-related changes in the oesophagus include delayed emptying undergo structural changes such as fibrosis, fatty acid deposits and
resulting from smooth muscle weakness and an incompetent LES.2 atrophy. Both obstructive and non-obstructive gall bladder diseases
Although motility of the GI system decreases with age, secretion and increase with age.6
absorption are affected to a lesser extent. The older person often has Older adults, especially those over 85, are at risk for decreased food
a decrease in HCl secretion (hypochlorhydria) and a subsequent intake.7 This may be related to economic circumstances, but is more
reduction in the amount of intrinsic factor secreted. likely to be related to the challenges of going shopping, the
Although constipation is a common complaint of older adults, availability of public transport and the efforts involved in cooking
age-related changes in colonic secretion or motility have not been nutritious meals. Age-related changes in the GI system and
consistently shown.3 Factors that may increase the risk for differences in assessment findings are presented in Table 35-5.

GERONTOLOGICAL ASSESSMENT DIFFERENCES

TABLE 35-5  Gastrointestinal system
Expected age-related changes Differences in assessment findings
Mouth
Gingival retraction Loss of teeth, dental implants, dentures, difficulty chewing
Decreased taste buds, decreased sense of smell Diminished sense of taste (especially salty and sweet)
Decreased volume of saliva Dry oral mucosa
Atrophy of gingival tissue Poor-fitting dentures
Oesophagus
Lower oesophageal sphincter pressure decreased, motility decreased Epigastric distress, dysphagia, potential for hiatal hernia and
aspiration
Abdominal wall
Thinner and less taut More visible peristalsis, easier palpation of organs
Decreased number and sensitivity of sensory receptors Less sensitivity to surface pain
Stomach
Atrophy of gastric mucosa, decreased blood flow Food intolerances, signs of anaemia as result of Vitamin B12
malabsorption, slower gastric emptying
Small intestines
Slightly decreased motility and secretion of most digestive enzymes Complaints of indigestion, slowed intestinal transit, delayed
absorption of fat-soluble vitamins
Liver
Decreased size and lowered position Easier palpation because of lower border extending past costal
margin
Decreased protein synthesis, ability to regenerate decreased Decreased drug and hormone metabolism
Large intestine, anus, rectum
Decreased anal sphincter tone and nerve supply to rectal area Faecal incontinence
Decreased muscular tone, decreased motility Flatulence, abdominal distension, relaxed perineal musculature
Increased transit time, decreased sensation to defecation Constipation, faecal impaction
Pancreas
Pancreatic ducts distended, lipase production decreased, pancreatic Impaired fat absorption, decreased glucose tolerance
reserve impaired

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 884 Section 8  Problems of ingestion, digestion, absorption and elimination

diarrhoea. Antacids and laxatives may affect the absorption of

CASE STUDY
certain medications. Ask the patient if laxatives or antacids are
Patient introduction taken, including the kind and frequency.
Patient profile Surgery or other treatment
Laurie Carlotto is a 58-year-old man from rural
Obtain information about hospitalisations for any problems
New South Wales. His wife and family have
driven 650 km to get him to the nearest base related to the GI system. Also obtain data related to any
hospital. He comes into the emergency abdominal or rectal surgery, including the year, reason for
department (ED) doubled over in pain. He is surgery, postoperative course and possible blood transfusions.
grimacing and holding his abdomen with Terms related to surgery of the GI system are presented in
both arms. You are working as the triage nurse Table 35-6.
Source: that morning.
Shutterstock/
William Perugini. Functional health patterns
Key questions to ask a patient with a GI problem are presented
Clinical reasoning in Box 35-2.
As you read through this chapter, think about Laurie Carlotto’s Health perception–health management pattern
symptoms with the following questions in mind:
1. What are the possible causes for Laurie Carlotto’s acute
Ask about the patient’s health practices related to the GI system,
abdominal pain? such as maintenance of normal body weight, proper dental care,
2. What would be your priority assessment? adequate nutrition and effective elimination habits.
3. What questions would you ask Laurie Carlotto? Query the patient about recent foreign travel with possible
4. What should be included in the physical assessment? What exposure to hepatitis or parasitic infestation. Ask about potential
would you be looking for?
5. What diagnostic studies might you expect to be ordered?
TABLE 35-6  Surgical procedures of the
Answers available at http://evolve.elsevier.com/AU/Brown/medsurg. gastrointestinal system
Surgical procedure Description

Document a history of chronic dieting and repeated weight Antrectomy Removal of antrum portion of the
stomach
loss and gain.8
Appendicectomy Removal of the appendix
Medications Bariatric surgery Obesity surgery, including gastric
The health history should include an assessment of the banding, vertical sleeve
patient’s past and current use of medications. The names of all gastrectomy, gastric bypass
drugs, and their frequency and duration of use, are important. Caecostomy Opening into caecum
This is a critical aspect of history taking, because many
medications may not only have an effect on the GI system Cholecystostomy Opening into gall bladder
but also may be affected by abnormalities of the GI system. Choledochojejunostomy Opening between common bile
The medication assessment should include information about duct and jejunum
over-the-counter (OTC) medications, prescription drugs, herbal Choledocholithotomy Opening into common bile duct for
products, vitamins and nutritional supplements. Note the use removal of stones
of prescription or OTC appetite suppressants.
Many chemicals and drugs are potentially hepatotoxic Colectomy Removal of the colon
(Box 35-1) and result in significant patient harm unless moni­ Colostomy Opening into colon
tored closely. For example, chronic high doses of paracetamol Gastrectomy Removal of the stomach
and non-steroidal antiinflammatory drugs (NSAIDs) may be
hepatotoxic. NSAIDs (including aspirin) may also predispose Gastrostomy Opening into stomach
a patient to upper GI bleeding, with an increasing risk as the Glossectomy Removal of the tongue
person ages. Other medications such as antibiotics may change
Hemiglossectomy Removal of half of the tongue
the normal bacterial composition in the GI tract, resulting in
Herniorrhaphy Removal of a hernia

BOX 35-1  Potentially hepatotoxic chemicals and Ileostomy Opening into ileum
drugs Mandibulectomy Removal of the mandible
Amiodarone Mercury Oesophagoenterostomy Removal of portion of the
Arsenic Methotrexate oesophagus with segment of colon
Azathioprine Nevirapine attached to remaining portion
Carbamazepine Niacin
Chloroform Paracetamol Oesophagogastrostomy Removal of oesophagus and
anastomosis of remaining portion to
Gold compounds Phosphorus
stomach
Halothane Statins
Isoniazid Sulphonamides Pyloroplasty Enlargement and repair of pyloric
Ketoconazole Thiazide diuretics sphincter area
6-mercaptopurine Thiazolidinediones
Vagotomy Resection of branch of vagus nerve

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 Chapter 35  Nursing Assessment: Gastrointestinal system 885

HEALTH HISTORY
TABLE 35-7  Gastrointestinal system
Health perception–health management Cognitive–perceptual
• Describe any measures used to treat GI symptoms such as diarrhoea • Have you experienced any change in taste or smell that has
or vomiting. affected your appetite?*
• Do you smoke?* Do you drink alcohol?* • Do you have any heat or cold sensitivity that affects eating?*
• Are you exposed to any chemicals on a regular basis?* Have you • Does pain interfere with food preparation, appetite or chewing?*
been exposed in the past?* • Do pain medications cause constipation, diarrhoea or appetite
• Have you recently travelled overseas?* suppression?*
Nutritional–metabolic Self-perception–self-concept
• Describe your usual daily food and fluid intake. • Describe any changes in your weight that have affected how you
• Do you take any regular vitamin or mineral supplements?* feel about yourself.
• Have you experienced any changes in appetite or food • Have you had any changes in normal elimination that have affected
tolerance?* how you feel about yourself?*
• Has there been a weight change in the past 6–12 months?* • Have any symptoms of GI disease caused physical changes that are
• Are you allergic to any foods?* a problem for you?*
Elimination Role–relationship
• Describe the frequency and time of day you have bowel • Describe the impact of any GI problem on your usual roles and
movements. What is the consistency of the bowel movement? relationships.
• Do you use laxatives or enemas?* If so, how often? • Have any changes in elimination affected your relationships?*
• Have there been any recent changes in your bowel pattern?* • Do you live alone? Describe how your family or others assist you
• Describe any skin problems caused by GI problems. with your GI problems.
• Do you need any assistive equipment, such as ostomy equipment, Sexuality–reproductive
raised toilet seat, commode? • Describe the effect of your GI problem on your sexual activity.
Activity–exercise Coping–stress tolerance
• Do you have limitations in mobility that make it difficult for you to • Do you experience GI symptoms in response to stressful or
procure and prepare food?* emotional situations?
Sleep–rest • Describe how you deal with any GI symptoms that result.
• Do you experience any difficulty sleeping because of a GI Value–belief
problem?* • Describe any culturally specific health beliefs regarding food and
• Are you awakened by symptoms such as gas, abdominal pain, food preparation that may influence the treatment of your GI
diarrhoea or heartburn?* problem.
*If yes, describe.

risk behaviours for hepatitis C exposure. Document whether in the family. Women with HNPCC also have an increased risk
the patient has received hepatitis A and B vaccination. of endometrial and ovarian cancer.
Assess the patient for habits that directly affect GI
functioning. The intake of alcohol in large quantities or for Nutritional–metabolic pattern
long periods has detrimental effects on the stomach mucosa. A thorough nutritional assessment is essential. Take a diet
Chronic alcohol exposure causes fatty infiltration of the liver history and inquire about both content and amount (portion
and can cause damage, leading to cirrhosis and hepatocellular size). Food preferences and preparation may vary by culture and
carcinoma. Obtain a history of cigarette smoking. Nicotine is socioeconomic status. Open-ended questions allow the patient
irritating to the GI tract mucosa. Cigarette smoking is related to express beliefs and feelings about the diet. For example,
to GI cancers (especially mouth and oesophageal cancers), patients can be asked to ‘tell me about your food and fluid intake
oesophagitis and ulcers. Smoking delays the healing of ulcers. over the past 24 hours’. A 24-hour dietary recall can be used to
Family history is an important component of this health analyse the adequacy of the diet. Assist the patient to recall the
pattern. Because of the relationship between colorectal and preceding day’s food intake, including early morning and night-
breast cancer, inquire about a history of either type of cancer time intake, snacks, liquids and vitamin supplements. You can
then evaluate the diet in relation to recommended servings using
the food pyramid (see Fig 36-1). A 1-week recall may provide
GENETIC RISK ALERT additional information on usual dietary patterns. Compare
weekday and weekend dietary intake patterns in relation to
Colorectal cancer
both the quality and the quantity of food.
• Colorectal cancer may run in families if first-degree relatives Ask the patient about the use of sugar and salt substitutes,
(parents, siblings) or many other family members (grandparents, use of caffeine, and amount of fluid and fibre intake. Note any
aunts, uncles) have had colorectal cancer. This is especially true changes in appetite, food tolerance and weight. Anorexia and
when family members are diagnosed with colorectal cancer
before the age of 50.
• Some genetic conditions associated with an increased risk of GENETIC RISK ALERT
colorectal cancer include:
Hereditary non-polyposis colorectal cancer (HNPCC), which is Inflammatory bowel disease (IBD)
caused by mutations in several different genes.
Familial adenomatous polyposis (FAP), which is characterised by • Persons with IBD have a genetic predisposition or susceptibility to
multiple polyps that are non-cancerous at first, but eventually the disease.
develop into cancer if not treated. Most cases of FAP are due to • First-degree relatives have a 5- to 20-fold increased risk of
mutations of the adenomatous polyposis coli (APC) gene. developing IBD.

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 886 Section 8  Problems of ingestion, digestion, absorption and elimination

weight loss may be a sign of cancer or inflammation. Decreased Self-perception–self-concept pattern

food intake can also be the consequence of economic problems Many GI and nutritional problems affect the patient’s self-
and depression. perception. Overweight and underweight people may have
Ask about food allergies and what GI symptoms occur problems related to self-esteem and body image. Repeated
with the allergic response. Inquire about dietary intolerances, attempts to achieve a personally acceptable weight can be
including lactose and gluten. discouraging and depressing for some people. The way a person
recounts a weight history can alert you to potential problems
Elimination pattern in this area.
Elicit a detailed account of the patient’s bowel elimination The need for external devices to manage elimination, such
pattern. Note the frequency, time of day, and usual consistency as a colostomy or an ileostomy, may be challenging for some
of stool. Document the use of laxatives and enemas, including patients. The patient’s willingness to engage in self-care and to
type, frequency and results. Investigate any recent change in discuss this situation provides you with valuable information
bowel patterns. related to body image and self-esteem.
Document the amount and type of fluid and fibre intake, The altered physical changes often associated with advanced
as these influence the frequency and consistency of stools. liver disease can be disturbing for the patient. Jaundice and
Inadequate intake of fibre can be associated with constipation. ascites cause significant changes in external appearance. Assess
Investigate the possible association between a skin problem and the patient’s attitude towards these changes.
a GI problem. Food allergies can cause skin lesions, pruritus
and oedema. Diarrhoea can result in redness, irritation and Role–relationship pattern
pain in the perianal area. External drainage systems, such as Problems related to the GI system such as cirrhosis, hepatitis,
an ileostomy or ileal conduit, may cause local skin irritation. ostomies, obesity and carcinoma may alter the patient’s ability
to maintain usual roles and relationships. A chronic illness may
Activity–exercise pattern necessitate leaving a job or reducing work hours. Changes in
Activity and exercise affect GI motility. Immobility is a risk body image and self-esteem can affect relationships.
factor for constipation.
Assess ambulatory status to determine if the patient is Sexuality–reproductive pattern
capable of securing and preparing food. If the patient is unable Changes related to sexuality and reproductive status can result
to do these tasks, determine if a family member or an outside from problems of the GI system. For example, obesity, jaundice,
agency is meeting this need. anorexia and ascites could decrease the acceptance of a potential
Note any limitation in patient’s ability to feed himself or sexual partner. An ostomy could affect the patient’s confidence
herself. Assess for access to a toilet. Identify the use of and related to sexual activity. Your sensitive questioning can identify
access to supplies such as a commode or ostomy supplies. potential problems.
Anorexia can affect the reproductive status of a female
Sleep–rest pattern patient. Obesity leads to reduced fertility and increased
miscarriage rates in women.9
GI symptoms can interfere with the quality of sleep. Nausea,
vomiting, diarrhoea, indigestion and bloating can produce
sleep problems and should be investigated. Ask the patient if
GI symptoms affect sleep or rest. For example, a patient with
CASE STUDY—cont’d
gastro-oesophageal reflux disease (GORD) may be awakened
because of burning, epigastric pain. Subjective data
A patient may have a bedtime ritual that involves a
A focused subjective assessment of Laurie
particular food or beverage. Herbal teas may be sleep-inducing. Carlotto revealed the following information:
Document individual routines and comply with these whenever • PMH: Negative history for medical or
possible to avoid sleeplessness. Hunger can prevent sleep and surgical problems.
should be relieved by a light, easily digested snack (unless • Medications: None.
contraindicated). • Health perception–health management:
Laurie Carlotto states he has not been
feeling well for the past several weeks. He
Cognitive–perceptual pattern Source: feels weak and is easily fatigued. Denies
Sensory alterations can result in problems related to the Shutterstock/ exposure to chemicals. No recent travel
acquisition, preparation and ingestion of food. Changes in William Perugini. outside of the country. Smokes
taste or smell can affect appetite and eating pleasure. Vertigo can approximately 1 packet of cigarettes/day
make shopping and standing at a stove difficult and dangerous. for 20 years. Drinks beer on a daily basis,
typically three or four bottles per day.
Heat or cold sensitivity can make certain foods painful to eat. • Nutritional–metabolic: Laurie Carlotto is 170 cm tall and
Problems in expressive communication limit the patient’s weighs 63 kg (BMI: 20.7 kg/m2). States has been losing weight
ability to state personal dietary preferences. If a patient is over the past several months and does not have an appetite.
diagnosed as having a GI disorder, ask questions to determine No food allergies.
his or her understanding of the illness and its treatment. • Elimination: States has had alternating episodes of
Both acute and chronic pain influences dietary intake. constipation and diarrhoea. He noticed some bright red blood
in stools. Has not had a bowel movement for 4 days.
Behaviours associated with pain include avoidance of activity, • Cognitive–perceptual: Rates pain as a 9 on a scale of 0–10.
fatigue, and disruption of eating patterns. Assess patients States pain comes and goes in waves. Prefers to lie still with
receiving opioid medications for constipation, nausea, sedation knees flexed and drawn into his abdomen.
and appetite suppression.

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 Chapter 35  Nursing Assessment: Gastrointestinal system 887

Coping–stress tolerance pattern have a thin white coating; the undersurface should be smooth.
Determine what is stressful for the patient and what coping Observe for any lesions. Using a tongue blade, inspect the
mechanisms the patient uses. Factors outside the GI tract can buccal mucosa and note the colour, any areas of pigmentation
influence its functioning. Both psychological and emotional and any lesions. Dark-skinned individuals normally have patchy
factors, such as stress and anxiety, influence GI functioning in areas of pigmentation. In assessing the teeth and gums, look
many people. Stress may be manifested as anorexia, nausea, for caries; loose teeth; abnormal shape and position of teeth;
epigastric and abdominal pain, or diarrhoea. Some diseases of and swelling, bleeding, discolouration or inflammation of the
the GI system, such as peptic ulcer disease and IBD, may be gingivae. Note any distinctive breath odour.
aggravated by stress. However, GI symptoms should never Inspect the pharynx by tilting the patient’s head back and
be attributed solely to psychological factors. depressing the tongue with a tongue blade. Observe the tonsils,
uvula, soft palate, and anterior and posterior pillars. Instruct the
Value–belief pattern patient to say ‘ah’. The uvula and soft palate should rise and
Assess the patient’s spiritual and cultural beliefs regarding remain in the midline.
food and food preparation. Whenever possible, respect these
preferences. Determine if any value or belief could interfere Palpation  Palpate any suspicious areas in the mouth. Note
with planned interventions. For example, if the patient with ulcers, nodules, indurations and areas of tenderness. The mouth
anaemia is a vegetarian, the suggestion of a high-meat diet would of the older adult requires careful assessment. Give particular
be inappropriate. Thoughtful assessment and consideration of attention to dentures (e.g. fit, condition), ability to swallow, the
the patient’s beliefs and values usually increase adherence and tongue and lesions. Ask the patient with dentures to remove
satisfaction. them during an oral examination to allow for good visualisation
and palpation of the area.
OBJECTIVE DATA
Physical examination Abdomen
Mouth Two systems are used to anatomically describe the surface
Inspection  Inspect the mouth for symmetry, colour and size. of the abdomen. One system divides the abdomen into four
Observe for abnormalities such as pallor or cyanosis, cracking, quadrants by a perpendicular line from the sternum to the
ulcers or fissures. The dorsum (top) of the tongue should pubic bone and a horizontal line across the abdomen at the

TABLE 35-8  Structures located in abdominal regions

Right upper quadrant Left upper quadrant Right lower quadrant Left lower quadrant
Liver and gall bladder Left lobe of liver Lower pole of Aright kidney Lower pole of left kidney
Pylorus Spleen Caecum and appendix Sigmoid flexure
Duodenum Stomach Portion of ascending colon RUQ LUQof descending colon
Portion
Head of pancreas Body of pancreas Bladder (if distended) Bladder (if distended)
RLQ LLQ
Right adrenal gland Left adrenal gland Right ovary and salpinx Left ovary and salpinx
Portion of right kidney Portion of left kidney Uterus (if enlarged) Uterus (if enlarged)
Hepatic flexure of colon Splenic flexure of colon Right spermatic cord Left spermatic cord
Portion of ascending and Portion of transverse and Right ureter Left ureter
transverse colon descending colon

Right Left
hypochondriac Epigastric hypochondriac
A B
RUQ LUQ Right Umbilical Left
lumbar lumbar
RLQ LLQ
Hypogastric
Right or Left
inguinal suprapubic inguinal

Figure 35-8  A, Abdominal quadrants. B, Abdominal regions.

LLQ, left lower quadrant; LUQ, left upper quadrant; RLQ, right lower quadrant; RUQ, right upper quadrant.

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 888 Section 8  Problems of ingestion, digestion, absorption and elimination

umbilicus (Fig 35-8, A and Table 35-8). The other system is heard, thus determining the lower border of the liver. Next,
divides the abdomen into nine regions (Fig 35-8, B), but start at the nipple line in the right midclavicular line and percuss
only the epigastric, umbilical, and suprapubic or hypogastric downwards between ribs to the area of dullness indicating the
regions are commonly assessed. upper border of the liver. Measure the height or vertical space
For the abdominal examination, good lighting should shine between the two borders to determine the size of the liver. The
across the abdomen. The patient should be in the supine position normal range of liver height in the right midclavicular line is
and as relaxed as possible. To help relax the abdominal muscles, 6 to 12.7 cm.
have the patient slightly flex the knees and raise the head of
the bed slightly. The patient should have an empty bladder. Use Palpation  Light palpation is used to detect tenderness or
warm hands when doing the abdominal examination to avoid cutaneous hypersensitivity, muscular resistance, masses and
eliciting muscle guarding. Ask the patient to breathe slowly swelling. Help the patient relax for deeper palpation. Keep
through the mouth. your fingers together and press gently with the pads of the
fingertips, depressing the abdominal wall about 1 cm. Use
Inspection  Assess the abdomen for skin changes (colour, smooth movements and palpate all quadrants (Fig 35-9, A).
texture, scars, striae, dilated veins, rashes, lesions), umbilicus Deep palpation is used to delineate abdominal organs and
(location and contour), symmetry, contour (flat, rounded masses (Fig 35-9, B). Use the palmar surfaces of your fingers
[convex], concave, protuberant, distension), observable to press more deeply. Again, palpate all quadrants and note
masses (hernias or other masses) and movement (pulsations the location, size and shape of masses, as well as the presence
and peristalsis). A normal aortic pulsation may be seen in the of tenderness. At the same time, observe the patient’s facial
epigastric area. Look across the abdomen tangentially (across expression and any verbalisation as this may indicate cues of
the abdomen in a line) for peristalsis. Peristalsis is not normally discomfort or pain.
visible in an adult but may be visible in a thin person. An alternative method for deep abdominal palpation is
the two-hand method. Place one hand on top of the other and
Auscultation  During examination of the abdomen, auscul­ apply pressure to the bottom hand with the fingers of the top
tate before percussion and palpation because these latter
procedures may alter the bowel sounds. Use the diaphragm
of the stethoscope to auscultate bowel sounds because they
are relatively high pitched. Use the bell of the stethoscope
to detect lower-pitched sounds. Warm the stethoscope in
your hands before auscultating to help prevent abdominal
muscle contraction. Listen in the epigastrium and in all four
quadrants (start in the lower right quadrant). Listen for bowel
sounds for at least 2 minutes. A perfectly ‘silent abdomen’ is
uncommon.10 If you are patient and listen for several minutes,
you will frequently find that the sounds are not absent but are
hypoactive. If you do not hear bowel sounds, note the amount
of time you listened in each quadrant without hearing bowel
sounds.
The frequency and intensity of bowel sounds vary depending
on the phase of digestion. Normal sounds are relatively high
pitched and gurgling. Loud gurgles indicate hyperperistalsis
and are termed borborygmi (stomach growling). The bowel
A
sounds are more high pitched (rushes and tinkling) when the
intestines are under tension, as in intestinal obstruction. Listen
for decreased or absent bowel sounds. Terms used to describe
bowel sounds include present, absent, increased, decreased,
high pitched, tinkling, gurgling and rushing.
Also listen for vascular sounds. Normally, no aortic
bruits should be heard. A bruit, best heard with the bell of
the stethoscope, is a swishing or buzzing sound and indicates
turbulent blood flow.

Percussion  The purpose of percussion of the abdomen is

to estimate the size of the liver and determine the presence of
fluid, distension and masses. Sound waves vary according to
the density of underlying tissues. Air produces a higher-pitched,
hollow sound termed tympany. Fluid or masses produce a short,
high-pitched sound with little resonance termed dullness.
Lightly percuss all four quadrants of the abdomen and assess B
the distribution of tympany and dullness. Tympany is the
predominant percussion sound of the abdomen. Figure 35-9  A, Technique for light palpation of the abdomen.
To percuss the liver, start below the umbilicus in the right B, Technique for deep palpation.
midclavicular line and percuss lightly upwards until dullness Source: Ball, 2015.

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 Chapter 35  Nursing Assessment: Gastrointestinal system 889

hand. With the fingers of the bottom hand, feel for organs and left lower rib cage forwards. Place your left hand below the left
masses. Practise both methods of palpation to determine which costal margin, and press it in towards the spleen. Ask the patient
one is more effective. to breathe deeply. The tip or edge of an enlarged spleen will be
Check a problem area on the abdomen for rebound tender­ felt by the fingertips. The spleen is normally not palpable. If
ness by pressing in slowly and firmly over the painful site. it is palpable, do not continue because manual compression of
Withdraw the palpating fingers quickly. Pain on withdrawal of an enlarged spleen may cause it to rupture.
the fingers indicates peritoneal inflammation. Because assessing The standard approach for examining the abdomen can
for rebound tenderness may produce pain and severe muscle be used on the older adult. The abdomen may be thinner
spasm, it should be done at the end of the examination and only and more lax unless the patient is obese. If the patient has
by an experienced practitioner. chronic obstructive pulmonary disease, large lungs or a low
To palpate the liver, place the left hand behind the patient diaphragm, the liver may be palpated 1 to 2 cm below the
to support the right eleventh and twelfth ribs (Fig 35-10). Press right costal margin.
the left hand forwards and place the right hand on the patient’s
right abdomen lateral to the rectus muscle. The fingertips should Rectum and anus
be below the lower border of liver dullness and pointed towards Inspect perianal and anal areas for colour, texture, masses,
the right costal margin. Gently press in and up. The patient rashes, scars, erythema, fissures and external haemorrhoids.
should take a deep breath with the abdomen so that the liver Palpate any masses or unusual areas with a gloved hand.
drops and is in a better position to be palpated. Try to feel the For a digital examination of the rectum, place a gloved,
liver edge as it comes down to the fingertips. During inspiration lubricated index finger against the anus while the patient gently
the liver edge should feel firm, sharp and smooth. Describe the bears down (Valsalva manoeuvre). Then, as the sphincter relaxes,
surface and contour and any tenderness. insert the finger. Point the finger towards the umbilicus. Try to
To palpate the spleen, move to the patient’s left side. Place the get the patient to relax. Insert the finger into the rectum as far as
right hand under the patient, and support and press the patient’s possible, and palpate all surfaces. Assess any nodules, tenderness
or irregularities. A sample of stool can be removed with the
gloved finger and checked for occult blood. However, a single
guaiac-based faecal occult blood test has limited sensitivity in
detecting colorectal cancer.
Findings of a normal physical assessment of the GI system
are given in Box 35-2. Gerontological differences in the GI
system and differences in assessment findings are described in
Table 35-5. Common assessment abnormalities are presented
in Table 35-9. A focused assessment is used to evaluate the
status of previously identified GI problems and to monitor for
signs of new problems. A focused assessment of the GI system
is presented later in this chapter.

BOX 35-2   Normal physical assessment of

A gastrointestinal system
Mouth
• Moist and pink lips
• Pink and moist buccal mucosa and gingivae without plaques or
lesions
• Teeth in good repair
• Protrusion of tongue in midline without deviation or
fasciculations
• Pink uvula (in midline), soft palate, tonsils and posterior pharynx
• Swallows smoothly without coughing or gagging
Abdomen
• Flat without masses or scars; no bruises
• Bowel sounds in all quadrants
• No abdominal tenderness; non-palpable liver and spleen
• Liver 10 cm in right midclavicular line
• Generalised tympany
Anus
B • Absence of lesions, fissures and haemorrhoids
• Good sphincter tone
• Rectal walls smooth and soft
Figure 35-10  A, Technique for liver palpation. B, Alternative • No masses
technique. • Stool soft, brown and haem negative
Source: Ball, 2015.

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 890 Section 8  Problems of ingestion, digestion, absorption and elimination

ASSESSMENT ABNORMALITIES
TABLE 35-9  Gastrointestinal system
Finding Description Possible aetiology and significance
Mouth
Ulcer, plaque on lips or in Sore or lesion Carcinoma, viral infections
mouth
Cheilosis Softening, fissuring and cracking of lips at Riboflavin deficiency
angles of mouth
Cheilitis Inflammation of lips (usually lower) with Often unknown
fissuring, scaling, crusting
Geographic tongue Scattered red, smooth (loss of papillae) Unknown
areas on dorsum of tongue
Smooth tongue Red, slick appearance Vitamin B12 deficiency
Leucoplakia Thickened white patches Premalignant lesion
Pyorrhoea Recessed gingivae, purulent pockets Periodontitis
Herpes simplex Benign vesicular lesion Herpes virus
Candidiasis White, curd-like lesions surrounded by Candida albicans
erythematous mucosa
Glossitis Reddened, ulcerated, swollen tongue Exposure to streptococci, irritation, injury, vitamin B deficiencies,
anaemia
Acute marginal gingivitis Friable, oedematous, painful, bleeding Irritation from ill-fitting dentures or orthodontic appliances, calcium
gingivae deposits on teeth, food impaction
Oesophagus and stomach
Dysphagia Difficulty swallowing, sensation of food Oesophageal problems, cancer of oesophagus
sticking in oesophagus
Haematemesis Vomiting of blood Oesophageal varices, bleeding peptic ulcer
Pyrosis Heartburn, burning in epigastric or Hiatal hernia, oesophagitis, incompetent lower oesophageal
substernal area sphincter
Dyspepsia Burning or indigestion Peptic ulcer disease, gall bladder disease
Odynophagia Painful swallowing Cancer of oesophagus, oesophagitis
Eructation Belching Gall bladder disease
Nausea and vomiting Feeling of impending vomiting, expulsion GI infections, common symptom of many GI diseases; stress, fear
of gastric contents through mouth and pathological conditions
Abdomen
Distension Excessive gas accumulation, enlarged Obstruction, paralytic ileus
abdomen, generalised tympany
Ascites Accumulated fluid within abdominal Peritoneal inflammation, heart failure, metastatic carcinoma,
cavity, eversion of umbilicus (usually) cirrhosis
Bruit Humming or swishing sound heard Partial arterial obstruction (narrowing of vessel), turbulent flow
through stethoscope over vessel (aneurysm)
Hyper-resonance Loud, tinkling rushes Intestinal obstruction
Borborygmi Waves of loud, gurgling sounds Hyperactive bowel as result of eating
Absent bowel sounds No bowel sounds on auscultation Peritonitis, paralytic ileus, obstruction
Absence of liver dullness Tympany on percussion Air from viscus (e.g. perforated ulcer)
Masses Lump on palpation Tumours, cysts
Rebound tenderness Sudden pain when fingers withdrawn Peritoneal inflammation, appendicitis
quickly
Nodular liver Enlarged, hard liver with irregular edge or Cirrhosis, carcinoma
surface
Hepatomegaly Enlargement of liver, liver edge >1–2 cm Metastatic carcinoma, hepatitis, venous congestion
below costal margin

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 Chapter 35  Nursing Assessment: Gastrointestinal system 891

TABLE 35-9  Gastrointestinal system cont’d

Finding Description Possible aetiology and significance
Splenomegaly Enlarged spleen Chronic leukaemia, haemolytic states, portal hypertension, some
infections
Hernia Bulge or nodule in abdomen, usually Inguinal (in inguinal canal), femoral (in femoral canal), umbilical
appearing on straining (herniation of umbilicus) or incisional (defect in muscles after
surgery)
Rectum and anus
Haemorrhoids Thrombosed veins in rectum and anus Portal hypertension, chronic constipation, prolonged sitting or
(internal or external) standing, pregnancy
Mass Firm, nodular edge Tumour, carcinoma
Pilonidal cyst Opening of sinus tract, cyst in midline just Probably congenital
above coccyx
Fissure Ulceration in anal canal Straining, irritation
Melaena Abnormal, black, tarry stool containing Cancer, bleeding in upper GI tract from ulcers, varices
digested blood
Tenesmus Painful and ineffective straining at stool Inflammatory bowel disease, irritable bowel syndrome, diarrhoea
secondary to GI infection (e.g. food poisoning)
Steatorrhoea Fatty, frothy, foul-smelling stool Chronic pancreatitis, biliary obstruction, malabsorption problems

FOCUSED ASSESSMENT CASE STUDY—cont’d

Gastrointestinal system Objective data: Physical examination
Use this checklist to make sure the key assessment steps have been A focused assessment of Laurie Carlotto
done. reveals the following: BP 120/74, heart rate
110, respiratory rate 24, temperature 38°C.
Subjective Abdomen firm and slightly distended. High-
Ask the patient about any of the following and note responses. pitched bowel sounds in upper quadrants.
No bowel sounds auscultated in left lower
Loss of appetite Y N quadrant. Mild abdominal palpation elicits
Abdominal pain Y N pain.
Changes in stools (e.g. colour, blood, consistency, Source: As you continue to read this chapter,
frequency) Y N Shutterstock/ consider diagnostic studies that may be
Nausea, vomiting Y N William Perugini. needed for Laurie Carlotto.
Painful swallowing Y N

Objective: Diagnostic
Check the following laboratory results for critical values.
Endoscopy: colonoscopy, sigmoidoscopy,
oesophagogastroduodenoscopy
CT scan
✓
✓
Diagnostic studies of the
Radiological series: upper GI, lower GI
Stool for occult blood or ova and parasites
✓
✓
gastrointestinal system
Table 35-10 presents common diagnostic studies of the GI
Liver function tests ✓
system. Selected diagnostic studies are described in more
Objective: Physical examination detail below.
Inspect For most diagnostic studies, make sure a signed consent
Skin for colour, lesions, scars, petechiae, etc. ✓
form for the procedure has been completed and that this is in the
Abdominal contour for symmetry and distension ✓ medical record. Generally a medical practitioner is responsible
Perianal area for intact skin, haemorrhoids ✓ for explaining various procedures and obtaining written consent.
However, nurses play an important role in teaching patients
Auscultate* about the procedures. When preparing the patient, it is important
Bowel sounds ✓ to ask about any known allergies to drugs, iodine, shellfish or
contrast media.
Palpate
Abdominal quadrants using light touch ✓ Many GI system diagnostic procedures require measures to
Abdominal quadrants using a deep technique ✓ cleanse the GI tract and the ingestion or injection of a contrast
medium or a radio-opaque tracer. Often the patient has a series
*Note: Do auscultation before palpation. of GI diagnostic tests done. Monitor the patient closely to ensure
adequate hydration and nutrition during the testing period.

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 892 Section 8  Problems of ingestion, digestion, absorption and elimination

Some diagnostic studies are especially difficult and series is used to identify disorders such as oesophageal strictures,
uncomfortable for the older adult. Adjustments may be needed polyps, tumours, hiatal hernias, foreign bodies and peptic ulcers.
during the preparation to avoid dehydration or worsening renal
function, and during testing for positioning. Close monitoring is Lower gastrointestinal series
needed to avoid problems such as dehydration from prolonged The purpose of a lower GI series (barium enema) examination
fluid restriction and diarrhoea from bowel-cleansing procedures. is to observe by means of fluoroscopy the colon filling with
contrast medium and to observe by X-ray the filled colon.
This procedure identifies polyps, tumours and other lesions
RADIOLOGICAL STUDIES in the colon. It consists of administering an enema of contrast
Upper gastrointestinal series medium to the patient. The air-contrast barium enema provides
An upper GI series with small bowel follow-through provides better visualisation (Fig 35-11). Because it requires the patient
visualisation of the oropharyngeal area, the oesophagus, the to retain the barium, it may not be tolerated as well in an older
stomach, and the small intestine via fluoroscopy and X-ray or immobile patient.
examination. The procedure consists of the patient swallowing
contrast medium (a thick barium solution or gastrograffin) Virtual colonoscopy
and then assuming different positions on the X-ray table. The Virtual colonoscopy combines computed tomography (CT)
movement of the contrast medium is observed with fluoroscopy, scanning or magnetic resonance imaging (MRI) with computer
and several X-rays are taken (see Table 35-10). An upper GI software to produce images of the colon and the rectum. The

DIAGNOSTIC STUDIES
TABLE 35-10  Gastrointestinal system
Study Description and purpose Nursing responsibility
Radiology
Upper gastrointestinal (GI) or X-ray study with fluoroscopy with contrast Explain procedure to patient, the need to drink
barium swallow medium. Study is used to diagnose structural contrast medium, and to assume various positions
abnormalities of the oesophagus, stomach and on X-ray table. Keep patient NBM for 6 hours
duodenum. before procedure. Tell patient to avoid smoking
after midnight the night before the study. After
X-ray, take measures to prevent contrast medium
impaction (e.g. fluids, laxatives). Tell patient that
stool may be white for up to 72 hours after test.
Small bowel series Contrast medium is ingested and films taken every Same as for upper GI.
30 minutes until medium reaches terminal ileum.
Lower GI or barium enema Fluoroscopic X-ray examination of colon using Before the procedure, administer laxatives and
contrast medium, which is administered rectally enemas until colon is clear of stool evening
(enema) (see Fig 35-11). Double-contrast or air- before procedure. Administer clear liquid diet
contrast barium enema is test of choice. Air is evening before procedure. Keep patient NBM for
infused after thick barium flows through the 8 hours before test. Instruct patient about being
transverse colon. given barium by enema. Explain that cramping
and urge to defecate may occur during
procedure and that patient may be placed in
various positions on tilt table.
After the procedure, give fluids, laxatives or
suppositories to assist in expelling barium.
Observe stool for passage of contrast medium.
Ultrasound Non-invasive procedure that uses high-frequency
sound waves (ultrasound waves), which are
passed into body structures and recorded as
they are reflected (bounded).
A conductive gel (lubricant jelly) is applied to the
skin and a transducer is placed on the area.
• Abdominal ultrasound Study detects abdominal masses (tumours and Instruct patient to be NBM 8–12 hours before
cysts) and is also used to assess ascites. ultrasound. Air or gas can reduce quality of
images. Food intake can cause gall bladder
contraction, resulting in suboptimal study.
• Hepatobiliary ultrasound Study detects subphrenic abscesses, cysts, Same as abdominal ultrasound.
tumours and cirrhosis, and is used to visualise
biliary ducts.
• Gall bladder ultrasound Study detects gallstones. Same as abdominal ultrasound.
• Oesophageal endoscopic Study detects and stages oesophageal tumours. Same as upper GI endoscopy.
ultrasound Fine-needle aspiration can be done to validate
cancer or dysplasia.

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 Chapter 35  Nursing Assessment: Gastrointestinal system 893

TABLE 35-10  Gastrointestinal system cont’d

Study Description and purpose Nursing responsibility
Computed tomography (CT) Non-invasive radiological examination combines Explain procedure to patient. Determine sensitivity
special X-ray machine used for CT, which allows to iodine if contrast material used.
for exposures at different depths. Study detects
biliary tract, liver and pancreatic disorders. Use of
contrast medium accentuates density
differences.
Magnetic resonance imaging Non-invasive procedure using radio frequency Explain procedure to patient. Contraindicated in
(MRI) waves and a magnetic field. Procedure is used to patient with metal implants (e.g. pacemaker) or
detect hepatic metastases and sources of GI who is pregnant.
bleeding, and to stage colorectal cancer.
Virtual colonoscopy Technique combines CT scanning or MRI with Bowel preparation is similar to colonoscopy (see
computer virtual reality software to detect colon below). Unlike conventional colonoscopy, no
and bowel diseases, including polyps, colorectal sedatives are needed and no scope is used.
cancer, diverticulosis and lower GI bleeding. Air Procedure takes about 15–20 minutes.
is introduced via a tube placed in rectum to
enlarge colon to enhance visualisation. Images
are obtained while patient is on back and
stomach. Computer combines images to form
2D and 3D pictures, which are viewed on
monitor.
Cholangiography
• Percutaneous transhepatic After local anaesthesia, liver is entered with long Observe patient for signs of haemorrhage or bile
cholangiogram (PTC) needle (under fluoroscopy), bile duct is entered, leakage. Assess patient’s medication for possible
bile withdrawn, and radio-opaque contrast contraindications, precautions or complications
medium injected. Fluoroscopy is used to with the use of contrast medium.
determine filling of hepatic and biliary ducts.
• Surgical cholangiogram Study is performed during surgery on biliary Explain to patient that anaesthetic will be used.
structures, such as gall bladder. Contrast Assess patient’s medication for possible
medium is injected into common bile duct. contraindications, precautions or complications
with the use of contrast medium.
• Magnetic resonance Non-invasive study that uses MRI technology to Same as MRI.
cholangiopancreatography obtain images of biliary and pancreatic ducts.
(MRCP)
• Nuclear imaging scans Purpose is to show size, shape and position of Tell patient that substances contain only traces of
(scintigraphy) organ. Functional disorders and structural radioactivity and pose little to no danger.
defects may be identified. Radionuclide Schedule no more than one radionuclide test on
(radioactive isotope) is injected IV and a counter the same day. Explain to patient the need to lie
(scanning) device picks up radioactive emission, flat during scanning.
which is recorded on paper. Only tracer doses of
radioactive isotopes are used.
• Gastric emptying studies Radionuclide study is used to assess ability of Same as above.
stomach to empty solids or liquids. In solid-
emptying study, cooked egg white containing
Tc-99m is eaten. In liquid-emptying study,
orange juice with Tc-99m is drunk. Sequential
images from gamma camera are recorded every
2 minutes for up to 60 minutes. Study is used in
patients with emptying disorders from peptic
ulcer, ulcer surgery, diabetes or gastric
malignancies.
• Hepatobiliary scintigraphy Patient is given IV injection of Tc-99m and Same as above.
(HIDA) positioned under camera to record distribution
of tracer in the liver, biliary tree, gall bladder and
proximal small bowel. Useful for identifying
diffuse hepatic disease (such as cirrhosis or
neoplasm), as well as to confirm acute
cholecystitis.
• Scintigraphy of GI bleeding Tc-99m-labelled sulphur colloid or Tc-99m Same as above.
labelling of the patient’s own red blood cells
(RBCs) can accurately determine the site of active
GI blood loss. The sulphur colloid or the patient’s
RBCs are injected, and images of the abdomen
are obtained at intermittent intervals.

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 894 Section 8  Problems of ingestion, digestion, absorption and elimination

TABLE 35-10  Gastrointestinal system cont’d

Study Description and purpose Nursing responsibility
Endoscopy
Upper endoscopy
• Oesophagogastroduodenoscopy Technique directly visualises mucosal lining of Before the procedure, keep patient NBM for
(OGD) oesophagus, stomach and duodenum with 8 hours. Make sure signed consent is on chart.
flexible fibre-optic endoscope. Test may use Give preoperative medication if ordered. Explain
video imaging to visualise stomach motility. to patient that local anaesthetic may be sprayed
Inflammations, ulcerations, tumours, varices or on throat before insertion of scope and that
Mallory-Weiss tear may be detected. Biopsies patient will be sedated during the procedure.
may be taken and varices can be treated with After the procedure, keep patient NBM until gag
band ligation or sclerotherapy. reflex returns. Gently tickle back of throat to
determine reflex. Use warm saline gargles for
relief of sore throat. Check temperature every
15–30 minutes for 1–2 hours. (Sudden
temperature spike is sign of perforation.)
Colonoscopy Study directly visualises entire colon up to Before the procedure, a bowel preparation is done.
ileocaecal valve with flexible fibre-optic scope. These vary depending on doctor. For example,
Patient’s position is changed frequently during patients may be kept on clear liquids 1–2 days
procedure to assist with advancement of scope before procedure. Cathartic and/or enema given
to caecum. Test is used to diagnose the night before. An alternative is to give 3 L of
inflammatory bowel disease, and to detect polyethylene glycol on the evening before
tumours, diverticulosis and dilate strictures. (250 mL glass every 15 minutes). Explain to
Procedure allows for biopsy and removal of patient that flexible scope will be inserted while
polyps without laparotomy. patient in side-lying position. Explain to patient
that sedation will be given.
After the procedure, be aware that patient may
experience abdominal cramps caused by
stimulation of peristalsis because the bowel is
constantly inflated with air during procedure.
Observe for rectal bleeding and signs of
perforation (e.g. malaise, abdominal distension,
tenesmus). Check vital signs.
Capsule endoscopy Patient swallows a capsule with camera Dietary preparation: similar to colonoscopy. The
(approximately the size of a large vitamin), which video capsule is swallowed and the patient is
provides endoscopic evaluation of GI tract (see usually kept NBM until 4–6 hours later. Procedure
Fig 35-13). Most commonly used to visualise is comfortable for most patients. Eight hours
small intestine and diagnose diseases such as after swallowing the capsule, the patient returns
Crohn’s disease, coeliac disease, irritable bowel to have the monitoring device removed.
syndrome and malabsorption syndrome, and Peristalsis causes passage of the disposable
identify sources of possible GI bleeding in areas capsule with a bowel movement.
not accessible by upper endoscopy or This procedure should not be carried out on
colonoscopy. patients with known or suspected strictures of
Camera takes about 57,000 images during 8-hour the small bowel.
examination. Capsule relays images to data
recorder that patient wears on belt. After the
examination, images are downloaded to a
computer and viewed on the monitor.
Sigmoidoscopy Study directly visualises rectum and sigmoid colon Administer enemas evening before and morning
with lighted flexible endoscope. Sometimes of procedure. Patient may have clear liquids day
special table is used to tilt patient into knee– before or no dietary restrictions may be
chest position. Test may detect tumours, polyps, necessary. Explain to patient knee–chest
inflammatory and infectious diseases, fissures, position (unless patient is older or very ill), need
haemorrhoids. to take deep breaths during insertion of scope,
and possible urge to defecate as scope is passed.
Encourage patient to relax—let abdomen go
limp. Observe for rectal bleeding after
polypectomy or biopsy.
Endoscopic retrograde Fibre-optic endoscope (using fluoroscopy) is Explain the procedure to the patient, including the
cholangiopancreatography inserted through the oral cavity into descending patient’s role. Keep patient NBM 8 hours before
(ERCP) duodenum, then common bile and pancreatic procedure. Ensure consent form signed.
ducts are cannulated. Contrast medium is Administer sedation immediately before and
injected into ducts and allows for direct during procedure. Administer antibiotics if
visualisation of structures. Technique can also be ordered.
used to retrieve a gallstone from distal common After the procedure, check vital signs. Check for
bile duct, dilate strictures, obtain biopsy of signs of perforation or infection. Be aware that
tumours, diagnose pseudocysts or insert pancreatitis is most common complication.
palliative stents. Check for return of gag reflex.

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 Chapter 35  Nursing Assessment: Gastrointestinal system 895

TABLE 35-10  Gastrointestinal system cont’d

Study Description and purpose Nursing responsibility
Endoscopic ultrasound Combined use of endoscopy and ultrasound using Similar to upper GI endoscopy.
an ultrasound transducer attached to an
endoscope. Enables visualisation of the walls of
the oesophagus, stomach, intestine, liver,
pancreas and gall bladder.
Oesophageal manometry The measurement of intraluminal pressure and the Explain the procedure to the patient. Consent
coordination of activity in the muscle of the is obtained. Patient is NBM for 6 hours, and
oesophagus. antireflux medication is stopped 5 days prior
to the procedure.
Anal rectal manometry The measurement of the pressures and Explain the procedure to the patient. Ensure
coordination of the anal sphincter. patient consent is obtained.
Laparoscopy (peritoneoscopy) Peritoneal cavity and contents are visualised with Make sure consent is signed. Keep patient NBM
laparoscope. Biopsy specimen may also be taken. 8 hours before study. Administer preoperative
Done under general anaesthesia in operating sedative medication. Ensure that bladder and
room. Double-puncture peritoneoscopy permits bowel are emptied. Instruct patient that local
better visualisation of abdominal cavity, anaesthetic is used before scope insertion.
especially liver. Technique can eliminate need for Observe for possible complications of bleeding
exploratory laparotomy in many patients. and bowel perforation after the procedure.
Blood chemistry
• Serum amylase Study measures secretion of amylase by pancreas Obtain blood sample in acute attack of
and is important in diagnosing acute pancreatitis. pancreatitis. Explain procedure to patient.
Level of amylase peaks in 24 hours and then
drops to normal in 48–72 hours. Depending on
method, normal finding is 0–130 U/L.
• Serum lipase Study measures secretion of lipase by pancreas. Explain procedure to patient.
Level stays elevated longer than serum amylase.
Normal finding is 0–160 U/L.
Liver biopsy Percutaneous procedure uses needle inserted Before the procedure, check patient’s coagulation
between sixth and seventh or eighth and ninth status (prothrombin time, clotting or bleeding
intercostal spaces on the right side to obtain time). Ensure that patient’s blood is typed and
specimen of hepatic tissue. Often done using cross-matched. Take vital signs as baseline data.
ultrasound or CT guidance. Explain holding of breath after expiration when
needle is inserted. Ensure that informed consent
has been signed.
After the procedure, check vital signs to detect
internal bleeding every 15 minutes × 2, every
30 minutes × 4, every 1 hour × 4. Keep patient lying
on right side for minimum of 2 hours to splint
puncture site. Keep patient in bed in flat position
for 12–14 hours. Assess patient for complications
such as bile peritonitis, shock, pneumothorax.
Miscellaneous tests
• Gastric analysis Purpose is to analyse gastric contents for acidity Keep patient NBM for 8–12 hours. Explain insertion
and volume. NG tube is inserted and gastric of NG tube. Withhold drugs affecting gastric
contents are aspirated. Contents are analysed secretions 24–48 hours before test. Ensure no
mainly for HCl, but pH, pepsin and electrolytes smoking morning of test. (Nicotine increases
may be determined. Histalog and pentagastrin gastric secretion.)
may be used to stimulate HCl secretion.
Exfoliative cytology may be done to determine
whether malignant cells are present. With
fasting, normal acidity is 2.5 mmol/L and normal
volume is 62 mL/h; 30 minutes after Histalog or
pentagastrin administration, normal acidity is
1.5 mmol/L and normal volume is 110 mL/h.
• Faecal analysis Form, consistency and colour are noted. Specimen Observe patient’s stools. Collect stool specimens.
examined for mucus, blood, pus, parasites and Check stools for blood with Haemoccult or
fat content. Tests for occult blood (guaiac test, Haematest. Keep diet free of red meat for
Haemoccult, Haematest) are done. 24–48 hours before guaiac test.
• Stool culture Tests for the presence of bacteria, including Collect stool specimen.
Clostridium difficile.
Faecal calprotectin Marker of intestinal inflammation. Collect stool specimen.
HCl, hydrochloric acid; NG, nasogastric; GI, gastrointestinal; IV, intravenous; NBM, nothing by mouth.

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 896 Section 8  Problems of ingestion, digestion, absorption and elimination

Ascending colon Transverse colon Descending colon

Ascending Ileocaecal fold
colon

Ileum

Ileocaecal
fold flaps

A Caecum Appendix B

Figure 35-12  A, Illustration showing the ileocaecal junction and

the ileocaecal fold. B, Endoscopic image of the ileocaecal fold.
Source: Drake, Vogl & Mitchell, 2010.

Sigmoid colon Rectum

Figure 35-11  Barium enema X-ray showing the large intestine.

Source: Drake, Vogl & Mitchell, 2010.

test is less invasive than a conventional colonoscopy but does

require radiation and prior cleansing of the colon. (The technique
A
is described in Table 35-10.)
Virtual colonoscopy enables one to better see inside a colon
that is narrowed due to inflammation or a growth.11 However, if
a polyp is discovered using virtual colonoscopy, a conventional
colonoscopy will then be needed to obtain a biopsy or remove
it. A disadvantage of virtual colonoscopy is that it may be less
sensitive in obtaining information on the details and colour of
the mucosa. In addition, it is less sensitive in detecting small
(less than 10 mm) or flat polyps.

ENDOSCOPY
Endoscopy refers to the direct visualisation of a body structure
through a lighted fibre-optic instrument. The GI structures
that can be examined by endoscopy include the oesophagus,
the stomach, the duodenum and the colon. The pancreatic,
hepatic and common bile ducts can be visualised with an
endoscope. This procedure is called endoscopic retrograde
cholangiopancreatography (ERCP).
The endoscope is an instrument through which biopsy
forceps and cytology brushes may be passed. Cameras are
attached, and video and still pictures can be taken (Fig 35-12). B
Endoscopy is often done in combination with biopsy and
cytology studies. Figure 35-13  Capsule endoscopy.
The major complication of GI endoscopy is perforation A, The video capsule has its own camera and light source. After it is
through the structure being scoped. All endoscopic procedures swallowed, it travels through the GI tract and allows visualisation of the
small intestine. It sends messages to a monitoring device that is worn on
require informed, written consent. Specific endoscopy a waist belt (B). During the 8-hour examination, the patient is free to
procedures are discussed in Table 35-10. In addition to diag­ move about. After the test, the images are viewed on a video monitor.
nostic procedures, many invasive and therapeutic procedures Source: Given Imaging Inc.
may be done with endoscopes. Examples include polypectomy,
sclerosis or banding of varices, laser treatment, cautery of
bleeding sites, papillotomy, common bile duct stone removal source of GI bleeding, small lesions, oesophageal varices,
and balloon dilation. Many endoscopic procedures require IV colonic polyps and colorectal cancer is under investigation.12
short-acting sedation.
Capsule endoscopy is a non-invasive approach to visualise LIVER BIOPSY
the GI tract (Fig 35-13). (See Table 35-10 for further discussion The purpose of a liver biopsy is to obtain hepatic tissue that can
of this diagnostic technique.) Its sensitivity in detecting the be used in establishing a diagnosis of or assessing fibrosis. It

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 Chapter 35  Nursing Assessment: Gastrointestinal system 897

c. the Kupffer cells in the liver are unable to remove bilirubin

CASE STUDY—cont’d from the blood.
Objective data: Diagnostic studies d. there is an obstruction in the biliary tract preventing flow
of bile into the small intestine.
The ED doctor performs a rectal examination 3. As gastric contents move into the small intestine, the bowel
that reveals a palpable mass. The following
diagnostic tests are ordered:
is normally protected from the acidity of gastric contents
• full blood count by the
• electrolytes a. inhibition of secretin release.
• liver function tests b. release of bicarbonate by the pancreas.
• urinalysis c. release of pancreatic digestive enzymes.
• CT scan of the abdomen d. release of gastrin by the duodenal mucosa.
Source: • colonoscopy. 4. A patient is jaundiced and her stools are clay coloured (grey).
Shutterstock/ The CBC reveals an Hgb of 68 g/L and an Hct
William Perugini. of 20%. The white blood cell count is normal. This is most likely related to
The electrolytes, liver function tests and a. decreased bile flow into the intestine.
urinalysis are within normal limits. The CT scan reveals pockets b. increased production of urobilinogen.
of gas and fluid in the ascending colon and two medium-sized c. increased production of cholecystokinin.
tumours in the transverse colon. d. increased bile and bilirubin in the blood.
5. An 80-year-old man states that, although he adds a lot of salt
to his food, it still does not have much taste. The nurse’s
may also be useful for following the progress of liver disease, response is based on the knowledge that the older adult
such as chronic hepatitis. a. should not experience changes in taste.
The two types of liver biopsy are open and closed. The open b. has a loss of taste buds, especially for sweet and salt.
method involves making an incision and removing a wedge of c. has some loss of taste but no difficulty chewing food.
tissue. It is done in the operating room with the patient under d. loses the sense of taste because the ability to smell is
general anaesthesia, often concurrently with another surgical decreased.
procedure. The closed, or needle, biopsy is a percutaneous 6. When the nurse is assessing the health perception–health
procedure in which the site is infiltrated with a local anaesthetic maintenance pattern as related to GI function, an appropriate
and a needle is inserted between the sixth and seventh or eighth question to ask is:
and ninth intercostal spaces on the right side. The patient lies a. ‘What is your usual bowel elimination pattern?’
supine with the right arm over the head. Instruct the patient to b. ‘What percentage of your income is spent on food?’
expire fully and not breathe while the needle is inserted (see c. ‘Have you travelled overseas in the last year?’
Table 35-10). d. ‘Do you have diarrhoea when you are under a lot of
stress?’
FIBROSCAN 7. During an examination of the abdomen, the nurse should
A fibroscan (transient elastrography) determines the stiffness a. position the patient in the supine position with the bed
(fibrosis) of the liver. It is non-invasive and useful in monitoring flat and knees straight.
disease progression and treatment decision making for patients b. listen in the epigastrium and all four quadrants for
with hepatitis C. The patient lies in the supine position with the 2 minutes for bowel sounds.
right arm in extreme abduction. The probe/transducer is placed c. use the following order of techniques: inspection,
in an intercostal space and a series of measurements are taken. palpation, percussion, auscultation.
d. describe bowel sounds as absent if no sound is heard in
LIVER FUNCTION STUDIES the lower right quadrant after 2 minutes.
Liver function tests (LFTs) are laboratory (blood) studies that 8. A normal physical assessment finding of the GI system is/are
reflect hepatic disease. Table 35-11, on the following page, (select all that apply)
describes some common LFTs. a. non-palpable liver and spleen.
b. borborygmi in upper right quadrant.
c. tympany on percussion of the abdomen.
REVIEW QUESTIONS
d. liver edge 2 to 4 cm below the costal margin.
1. A patient is admitted to the hospital with a diagnosis of e. finding of a firm, nodular edge on the rectal
diarrhoea with dehydration. The nurse recognises that examination.
increased peristalsis resulting in diarrhoea can be related to 9. In preparing a patient for a colonoscopy, the nurse explains
a. sympathetic inhibition. that
b. mixing and propulsion. a. a signed consent is not necessary.
c. sympathetic stimulation. b. sedation may be used during the procedure.
d. parasympathetic stimulation. c. only one cleansing enema is necessary for preparation.
2. A patient has an elevated blood level of indirect d. a light meal should be eaten the day before the
(unconjugated) bilirubin. One cause of this finding is that procedure.
a. the gall bladder is unable to contract to release stored
bile. Answers to the questions are found in Appendix C. For rationales
b. bilirubin is not being conjugated and excreted into the to these answers, visit http://evolve.elsevier.com/AU/Brown/
bile by the liver. medsurg/

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 898 Section 8  Problems of ingestion, digestion, absorption and elimination

DIAGNOSTIC STUDIES
TABLE 35-11  Liver function tests
Test Description and purpose
Bile formation and excretion
• Serum bilirubin Measurement of ability of liver to conjugate and excrete bilirubin, allowing differentiation between
unconjugated (indirect) and conjugated (direct) bilirubin in plasma
Total Measurement of direct and indirect total bilirubin
Normal finding of <20 mmol/L
Direct Measurement of conjugated bilirubin; elevation in obstructive jaundice
Normal finding of <7 mmol/L
Indirect Measurement of unconjugated bilirubin; elevation in hepatocellular and haemolytic conditions
Normal finding of 1.7–17 mmol/L
• Urinary bilirubin Measurement of urinary excretion of conjugated bilirubin
Normal finding of 0
• Urinary urobilinogen Measurement of urinary excretion of urobilinogen; maximum excretion mid-afternoon to early evening,
collection of total urinary output for 2 hours in afternoon, sent to laboratory in dark container
immediately because of oxidation of urobilinogen to urobilin on exposure to air
Normal finding of 0.8–6.8 mmol/day
• Faecal urobilinogen Measurement of faecal urobilinogen in stool specimen
Normal finding of 51–372 mmol/100 g of stool
Dye excretion tests (detoxification)
• Indocyanine green Determination of liver’s ability to take up and excrete dye given IV; take blood samples every 5 minutes
for 20–30 minutes
Normal finding of 500–800 mL/m2 of body surface area/minute
Protein metabolism
• Serum protein levels Measurement of serum proteins that are manufactured by the liver; measurement of albumin, normal
finding of 32–45 g/L; measurement of globulin, normal finding of 25–35 g/L
Normal total protein of 62–80 g/L
Normal albumin/globulin ratio of 1.5:1–2.5:1
• a-fetoprotein Indication of hepatic cancer
Normal finding of <16 mg/L
• Blood ammonia levels Conversion of ammonia to urea normally occurs in the liver; elevation can result in hepatic
encephalopathy secondary to liver cirrhosis
Normal finding of <50 mmol/L
Haemostatic functions
• Prothrombin Determination of prothrombin activity
Normal finding of 11–15 seconds
• Vitamin K production Determination of response of liver to vitamin K; checking of prothrombin time necessary 24 hours after
injection of vitamin K
Serum enzyme tests
• Alkaline phosphatase (ALP) Originating in bone and liver; serum levels rise when excretion is impaired as a result of obstruction in
the biliary tract.
Normal finding of 30–120 U/L, depending on method and age
• Aspartate aminotransferase Elevation in liver damage and inflammation
(AST) Normal finding of <40 U/L
• Alanine aminotransferase (ALT) Elevation in liver damage and inflammation
Normal finding of <35 U/L
• g-glutamyltranspeptidase (GGT) Present in biliary tract (not in skeletal muscle or cardiac); increase in hepatitis and alcoholic liver disease;
more sensitive for liver dysfunction than ALP
Normal finding of <50 U/L in men; <30 U/L in women
Lipid metabolism
• Serum cholesterol Synthesis and excretion by liver; increase in biliary obstruction; decrease in extensive liver disease and
malnutrition
Normal finding of <4.0 mmol/L, varying with age (see Table 28-7 for more detailed discussion)
IV, intravenous.

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 Chapter 35  Nursing Assessment: Gastrointestinal system 899

9. Boots C, Stephenson MD. Does obesity increase the risk of

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