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GI Ass. Test 4

Gastrointestinal Assessment

QuestionAnswer
What is the nurse's Comprehensive GI exam examing? nutritional status, abdomen, bowel sounds, appetite, bowel habits, oral cavity, special diet, also any medical history that might be associated with the patient.
The sequencing for doing a GI assessment is? Inspection Auscultation Percussion (but the nurses do not do this step, usually done by the MD)Palpation
Why do you auscultate before you palpate in the GI Ass.? Because palaption and percussion cause movement or stimulation of the bowel, which can increase bowel motility and thus heighten bowel sounds, creating false results.
What would you be inspecting the oral cavity(mouth) for? white spots, redness, severe dryness, are the mucous membranes moist and pink. Are the gums pink (dark skinned patients it is normal for gums to be darker. mobility of their tongue areoung so that you can check underneath it.
When inspecting the teeth? What are some things that you want to look at? If the patient has dentures, do they fit? Look at the gums, is there any bleeding are they healthy? Does the patient have any difficulty swallowing?
When inspecting the abdomen, what to you want to note? Obese abdomen, distended, concave or convex, drains, tubes, ostomies.
The landmarks of the abdomen (4) Left upper quadrantLeft lower quadrantRight Lower quadrantRight Upper Quadrant
The two imaginary lines that the nurse visualizes to seperate the quadrants are extending from where? from the sternum down to the top of the pubic symp.; straight across the umbilicus cord.
The Right upper quad. contains? liver gallbladder duodenum, head of the pancreas, right adrenal gland, upper lobe of the right kidney, hepatic part of colon,section of ascending and transverse colon
The Right lower quad. contains? lower lobe of the kidney, cecum, appendix, section of the ascending colon, R ovary, R, fallopian tube, R ureter, R spermatic cord, part of the uterus.
The Left lower quad. contains? lower lobe of the kidneys,sigmoid colon, L ovary, L fallopian tube, L ureter, L spermatic cord, part of the uterus.
The Left upper quad. contains? left lobe of the liver, stomac,spleen, upper lobe of the left kidney, pancreas,L adrenal gland, splenic flexure of colon, section of the transvers and descending colon.
Bad things that would be assessed when inspecting the abdomen are: is skin free from rash, lesions, ulcers,edema, is the skin purple or any discoloration, distention.
What is a scaphoid abdomen? A convexed adbomen
An example of a rounded abdomen would be? concave
Parasylis is? no bowel sounds, report to the doctor immediately.(Remember before you can say that there are no bowel sounds present, you have to wait 5 min. of ausculation.)
Normoacitve bowel sounds are heard every? 5-20 seconds (gurgles)
Hyperactive bowel sounds are heard every? 3 sec
Hypoactive bowel sounds are heard every? 1 min.
Ask about N_____, V______, S_______ nausea, vomiting, stool (bowel movement) * Be sure to ask them about the consistancy, color, odor, and if it is regular pattens
Before you palpate, you should ask the patient if he/she has had any pain or tenderness in the abdomen. Why is it important to do this? It is important because you would want to palpate this are last. Remembering to ask the patient how is the pain on a scale and allowing them to show you exactly where it hurts.* when does it hurt?* what makes it it worse?
Nurses do Light Palpation or Deep Palpation? Light palpation (1cm) circular motions in each quarant of the abdomen.
What do you do if the patient is extremely ticklish? You put your patients hands on their stomach and eventually slide their hands from under yours.
Created by: degutter
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