Health History Assessment-gastrointestinal
with the bell of the stethoscope. Assess all four
If GI symptoms cause the patient pain or discomfort,
you will need to move quickly through the
assessment. However, any GI complaint must
incorporate a health history, even if extremely brief.
Assess the following areas in the health history:
Pain: Perform a pain assessment to include specific
questions about when the pain occurs – before
meals, after meals, in the middle of the night, and
any food associations. Specifically ask about
heartburn and problems with a sore mouth, tongue,
or throat.
Teeth/Gums: Ask about problems with bleeding
gums, dental caries, abscesses, and use of dentures
and partial plates. Obtain date of last dental exam
and results if possible.
Throat: Ask about any hoarseness or voice changes
that might indicate the presence of a tumor, any
difficulty swallowing, and the presence or absence of
tonsils.
Appetite: Assess any changes in appetite, food
intolerances, and the presence of nausea and/or
vomiting.
Lower GI: Assess for problems with eructation,
flatulence, hemorrhoids, hernia.
The patient should be questioned about the use of
laxatives and antacids and the color, frequency, and
amount of stools. Assess previous GI disease history
such as cholecystitis, inflammatory bowel disease, or
cancer.
Physical Assessment
Mouth and Throat: Assess the mouth and throat for
sores, condition of teeth and gums, irritations, or any
other conditions that could affect the intake of food
and liquid. Lift the tongue and look under it for any
tumors or lesions. Assess for any unusual breath
odor.
Abdomen: Inspect for contour, symmetry, abdominal
aorta pulsation, and distention. Do not touch the
abdomen during the inspection or peristalsis can be
stimulated which will provide false data during the
auscultation portion of the assessment. Instruct the
patient to not touch the abdomen during the
inspection phase.
Auscultation
Bowel Sounds: Bowel sounds are best heard with the
diaphragm portion of the stethoscope. Note the
character (high-pitched, gurgling, clicking, etc.) and
frequency. Normally the sounds occur intermittently
at 5-15 times per minute. Judge if the sounds are
normal, hypoactive or hyperactive. You must listen
for 5 minutes to each quadrant before deciding that
bowel sounds are absent (20 minutes is unrealistic to
expect someone to stand and listen for bowel sounds
so we often rely on the patient’s other signs and
symptoms). If the patient is experiencing an
obstruction due to an ileus (absence of peristalsis),
bowel sounds will be absent as there is no enervation
by the nervous system to the area. If the patient is
experiencing a mechanical obstruction (feces,
volvulus, tumor, etc.), the bowel sounds can alter
between being hyperactive (as the gut tries to push
feces around the obstruction) or absent (as the gut
rests and prepares for the next peristaltic wave; the
patient will also complain of pain when bowel sounds
are heard). Peritonitis presents with absent bowel
sounds.
Vascular sounds: Vascular sounds are best heard
quadrants listening for bruits (whooshing, blowing
sounds that represent impaired circulation within an
artery or an aneurysm). An aortic pulsation may be
heard over the left upper quadrant in the presence of
hypertension, aortic insufficiency, or aortic
aneurysm.
Percussion
Tympani: Tympani should predominate as air rises to
surface of the abdominal cavity.
Hyperresonance: Will be heard in the presence of
gaseous distention.
Dullness: Percussed over a distended bladder,
adipose tissue, fluid, or a mass in the abdomen.
Palpation: Prior to palpating the abdomen, have the
patient bend the knees and relax the abdominal
muscles. Ask the patient to point to any painful or
tender areas. Save those areas to palpate last so the
patient becomes more accustomed to your touch and
does not guard throughout the exam. Lightly palpate
the abdomen by quadrants. Note any muscle
guarding, rigidity, tenderness, or masses.
Rectal Area: Examine the external rectal area for the
presence of external hemorrhoids, masses or
evidence of inflammation.
Health History Assessment-genitourinary
Urinary: Hesitancy, frequency, urgency, dysuria,
pyuria, polyuria, oliguria, nocturia, renal or urethral
calculi, hematuria, incontinence, urinary retention,
dribbling, testicular pain, poor stream, history of UTI,
color and odor of urine, and history of urinary
catheterization should be obtained.
Female Genitalia: Infection, prolapse, leukorrhea,
vaginal discharge, odor, pruritus, lesions, pain, date
and result of last pap smear, and history of sexually
transmitted diseases should be assessed.
Male Genitalia: Lesions, pain, prostate problems,
masses, infections, discharge, pruritus, hernia
testicular pain, and history of sexually transmitted
disease should be assessed.
Sexual: Dyspareunia (painful intercourse in the
female), birth control used, degree of sexual activity,
and sexual preference should be obtained.
Menstrual: Age of onset, regularity, menopause (date
of onset), post-menopausal bleeding, last menstrual
period (LMP) date, amount of flow (number of
pads/tampons/day), duration of menses, PMS, and
dysmenorrhea should be assessed.
Obstetrical: Chronological sequence of pregnancies
(weight and sex of each child), abortion,
miscarriages, blood transfusions, stillbirths,
complications of pregnancies, and rH sensitivity
history should be obtained.
Physical Assessment
Abdominal - Male & Female Genitalia - Perineal Area
Stephanie J. Pawelek RN, MSN
Quadrants
* Commit to memory the location of abdominal
organs according to quadrants
Four quadrant approach is most common
May see three of the nine regions used:
Epigastric
Umbilical
Hypogastric or suprapubic
Inspect The Contour
Of The Abdomen
Normally, contour is flat or rounded
Abnormalities -
A large convex symmetrical profile (protuberant or
distention)
A concave symmetrical profile (scaphoid)
Guidelines for measuring abdominal girth with
abdominal distention
Inspect Abdominal Movement
Respiratory movements:
Observe for smooth, even respiratory movement
Normally, no retractions
Normally, see rise with inspiration and fall with
expiration
Aortic pulsations:
Inspect epigastic area for pulsations
Normally, may or may not be visible
Abnormality - marked, strong pulsations
Inspect Abdominal Movement (Cont’d.)
Visible peristaltic waves:
Observe abdominal surface
Normally, none seen
May be visible in very thin individuals
Abnormalities - waves that are increased and
progress in a ripple-like fashion from the LUQ to the
RUQ
Auscultate For Bowel Sounds
Listen to the frequency and the character
Its necessary to listen for at least 5 minutes in a
quadrant before concluding they are absent
Normally heard as intermittent gurgling sounds
Usually the are high-pitched sounds and occur 5 to
30 times per minute
Auscultate For Bowel Sounds (Cont’d.)
Normally they are always present at the ileocecal
valve area (RLQ)
Borborygmi: Normal hyperactive BS
Loud, audible, gurgling sounds
May be due to "stomach growling" or sound of flatus
moving in the intestines
If auscultating postoperatively, sounds will return
gradually
Auscultate For Bowel Sounds (Cont’d.)
Abnormal findings:
Absent bowel sounds
Hypoactive bowel sounds
Hyperactive bowel sounds
Auscultate For Vascular Sounds
Listen for bruits: low-pitched, murmur-like
Normally none heard
Abnormality -
Bruits indicates turbulence of blood flow and
suggests partial obstruction
*NEVER palpate over areas where bruits are present
- softness
May cause rupture; refer to MD ASAP
Auscultate For Venous Hum
Normally none present (rare)
Abnormality -
Venous hum in the periumbilical area that is usually
due to obstructed portal circulation
Auscultate For Friction Rub
Listen in all four quadrants
None should be present (rare)
If heard, they have high-pitched sounds which
increase with inspiration
Objectives For Percussion
Lightly percuss clockwise for tone
Note when tympany changes to dullness
Tympany:
Predominant sound because air is present in stomach
and intestines
High-pitched sound of long duration
Dullness:
Normally heard over organs
High-pitched sound of moderate duration
Percussion Of Organs: Liver
To assess the lower border:
Begin in the RLQ at the mid-clavicular line (MCL)
below the umbilicus and percuss upward
Note the change from tympany to dullness and mark
this point - this is the lower border
Lower border of liver dullness is located at the costal
margin to 1 to 2 cm below
Percussion Of Organs: Liver (Cont’d.)
To assess the upper border:
Percuss over the upper right chest at the MCL and
percuss downward
Note the change from lung resonance to liver
dullness and mark this point - it is the upper border
The upper border of liver dullness is located b/n the
left fifth to seventh intercostal spaces
Percussion Of Organs: Liver
To determine the span or height of the liver:
Measure the distance between the two marks
Normal liver span at the MCL is 6 to 12 cm
Hepatomegaly : a liver span that exceeds normal
limits (enlarged) and is seen with various liver
diseases
Percussion Of Organs: Bladder
Percuss upward from the symphysis pubis to the
umbilicus
Note where the sound changes from dullness to
tympany
Normally:
A urine-filled bladder is dull
A recently emptied bladder should not be
percussable above the symphysis pubis
Percussion Of Organs: Kidneys
Blunt percussion is done to assess for tenderness
Perform at the costovertebral angles (CVA) over the
12th rib
Requires client sitting with his/her back to you
Normally, no tenderness or pain is felt
Abnormalities - tenderness or sharp pain
Light Palpation In General
Start with this first - avoid touching tender or painful
areas until LAST, and reassure client
Perform all over entire abdominal area - looking for
masses/tenderness
Do not confuse a mass with a normally palpated
structure
Abdomen should feel smooth with consistent
Light Palpation: Aortic Pulse
Press the upper abdomen with one hand on each
side of the abdominal aorta (supine)
Assess width of the aorta
Normally:
Width is 2.5 to 4.0 cm
Moderately strong and regular pulse
Possible mild tenderness
Abnormality:
Wide, bounding pulse
CAUTION: may rupture - notify MD ASAP
Normal Findings With Palpation
No organ enlargement should be palpable nor should
there be any abnormal masses, bulges, or swelling
Normally, only the aorta and the edges of the liver
are palpable
When the large colon or the bladder is full, palpation
is possible but is atypical

Inspection Of The Male Genitalia

Abnormalities -
Nits or lice
Lesions/nodules
Pain
Inflammation
Swelling/bulges
Discharge
Warning signs of STD’s:
Penile discharge, bloody or purulent
Scrotal or testicular pain
Burning or pain during urination
Penile lesion

Inspection Of The Female Genitalia

Abnormalities -
Parasites
Ecchymosis/ excoriation/nodules
Swelling/rash/lesions
Discharge/foul odors
Redness/inflammation/bulging

Inspection Of The Perineum/Anus

Perineal abnormalities -
Lesions
Swelling/inflammation
Tenderness
Feces/mucus on the perineal skin
Anal abnormalities-
Lesions/inflammation
Rash/masses
Additional openings
Anal opening should be closed
Leakage of feces/mucus
Tissue protrusion