NUR 3065C Jon Decker, PhD, ARNP, FNP-BC Gastrointestinal System Subjective Wt changes? Appetite? Dysphagia? Solids? Liquids?

Food intolerance? Sx? N/V? Freq Hematemesis Timing Associated symptoms? Bowel habits? Frequency Color Consistency Changes Bleeding Hematochezia (frank) lower GI Melena or tarry (occult) upper GI PHx? Surgeries? FHx? CA, polyps, IBD, IBS Medications? Antacids (Pepto?) NSAIDS Fe+ ETOH Hemorrhoids? Pruritis ani? Fistulas? Fissures? Nutritional assessment? Tobacco? ETOH? Caffeine? Developmental Infants/children Breast or formula?

Whole milk 1yr Intro of solids Fe+ Pica Teens Eating patterns Body image Aging Adult Pernicious Anemia Wt changes Bowel preoccupation Achalasia Dec. esoph peristalsis & LES constriction - dysphagia Objective Patient Preparation: Lighting Empty bladder (? Specimen) Warm room, stethoscope, & hands Abd: Supine/knees bent Rectal: (male) L lateral recumbent or standing fwd. flexed Rectal: (female) L lateral or lithotomy Quadrants Epigastrum Hypogastrum suprapubic Periumbilical RUQ LUQ RLQ LLQ CVA Retroperitoneal Sequence 1. Inspect 2. Auscultate Then 3. Percuss

4. Palpate Inspect Demeanor Relaxed Agitated Abdomen Contour Scaphoid Flat Rounded Protuberant Distended Pulsations Waves of peristalsis Lesions/rashes Scars Striae 7 Fs of Abdominal Distension Fat Fluid (ascites) Flatus Feces Fetus Fatal (malignancy) Fibroids Rectal: Anal fissures Hemorrhoids Rectal discharge Prolapse Papilloma (condyloma) Imperforate anus

Auscultate Bowel Sound Press lightly with warmed diaphragm All 4 quad - begin RLQ (ileocecal) - BS always here normally

Note: Character & Frequency Normal (5-30x/min) 3

Hyperactive Borborygmus Hypoactive Absent (0 x5) Vascular Sounds Press more firmly Vascular Sounds Bruits Aorta Renal Iliac Femoral Percuss All 4 quads Tympany predominates Dull = solid Liver Span Percuss CVAT - direct or indirect Percuss splenic dullness 9-11th ICS L MAL

Palpate Palpate for: Size Loci Shape Consistency Surface Mobility Pulsatility Tenderness Light then Deep 1cm > 5-8cm Use palmar surface fingers Bimanual technique: Lge abd Retroperitoneal organs Duck bill

Liver Palpation Bimanual technique Alternative Hooking Technique to palpate the lower margin of liver Liver (GB) Murphys sign take a deep breath Inspiration depresses liver/GB for palpation under costal margin (+) inspiratory arrest Aorta Palpate just to L of umbilicus w/ opposing fingers Nl = 2.5- 4 cm wide AAA (Not for your car) Kidneys/Adrenals Bimanual (AP) technique Slide hands laterally May palpate R lower pole No changes felt with deep inspiration Spleen Bimanual AP Only palpable when 3x nl size Roll sl. right Palpation Hints

Tender area last Voluntary guarding vs. involuntary rigidity Knees bent ?Ticklish

Anus, Rectum & Prostate Position: Lateral recumbant (L side/R knee flexed) Dorsal lithotomy Fwd over table Check sphincter tone (anal wink) Gloved index finger w/ lubricant Valsalva

Masses? Hemorrhoids (int/ext) ? Prostate @ 2.5x4 cm Smooth Rubbery Nontender Heart shaped Examine Stool Color/Consistency Guaiac-occult blood Abnormals: Jelly-inflammation Bright red (hematochezia)-lower GI Tarry (melena)- upper GI Black-Fe+, Pepto Gray/tan-hepatobilliary Greasy/fatty-malabsorption steatorrhea Developmental Changes Infants/Children Umbilical = 2A 1V Lge liver & most organs palpable Protuberant > 4 yrs. BS only, no vascular sounds on auscultation Aging Adult Inc. fatty deposits abd. & hips Muscle atrophy = organs easily palpable Referred Pain Special Procedures Rebound tenderness ?peritonitis Shifting dullness/Ascites Obturator Sign Iliopsoas Sign Other Pathology Umbilical hernia Diastasis recti Gastroschisis Volvulus Intussusception Omphalocele