Module 6 - GI GU Assessment PDF

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NUR3138 Module 6: GI/GU Assessment I.

Examining the Abdomen A. Preparing the Client 1. Promote client comfort a. Explain the procedure b. Develop rapport – focused history questions c. Provide privacy and comfort d. Use proper positioning i. Supine with knees flexed (relax abdominal muscles) 2. Focused history questions a. What would you ask specific to abdominal assessment? b. r/t diet, abdominal pain, BMs (blood, diarrhea, constipation, frequency), trouble swallowing, n/v, personal or family hx of abdominal disease or problems, difficulty voiding/burning/incontinence/back pain, meds? B. SPICES Assessment Tool 1. Sleep disorders 2. Problems with eating or feeding 3. Incontinence 4. Confusion 5. Evidence of falls 6. Skin breakdown C. Basic Assessments: Abdomen (know location of organs r/t abdominal quadrants) 1. Different order for assessment skills a. Inspect b. Auscultate c. Percuss d. Palpate – bladder? 2. Which order do we normally follow?

3. D. Inspection 1. Size, symmetry, contour a. Flat b. Rounded

NUR3138 c. Scaphoid d. Protuberant i. Umbilical hernia  Normally: umbilicus is inverted and midline with NO discolorations or discharge  If protruding, could be umbilical hernia or mass 2. Skin & skin color a. Lesions, scare, striae (stretch marks), superficial veins (liver disease, ABD?), hair distribution 3. Movement a. Peristalsis b. Aortic pulsations – (ABD?) 4. Aortic Aneurysm (AAA) a. Usually is asymptomatic i. Extreme pain if ruptures b. Most common cause is atherosclerosis c. Surgical repair is indicated for AAA > 5.5 cm in diameter or any size AAA with rapid growth d. Risk factors: i. Smoking ii. Male gender iii. Hypertension iv. Advanced age E. Auscultation – Bowel Sounds 1. Using diaphragm of stethoscope 2. Bowel sounds are high-pitched, irregular gurgles or clicks lasting one to several seconds and occurring every 5 to 15 seconds a. What are alterations? i. Hyperactive: < 2-3 sounds/sec ii. Hypoactive: > 5 sounds/min iii. Absent: 5+ mins w no sounds 3. Listen to all four quadrants a. RLQ (start) b. RUQ c. LUQ d. LLQ

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Bowel Sounds – Auscultating Bruits 1. Using bell of stethoscope 2. Over abdominal arteries 3. Bruits may indicate aneurysm or altered blood flow

4. G. Percussion – Abdomen 1. Use indirect percussion to assess for fluid, air, organs, or masses 2. What sounds are you looking for? a. Normal: tympany, with dullness over organs or fluids, is present i. No tenderness H. Percussion – Kidneys 1. Percuss the costovertebral angle (i.e., where the end of the rib cage meets the spine) a. Pain or tenderness is associated with kidney infection or musculoskeletal problems I. Palpation – How do you perform? 1. Light palpation 2. If pain palpate that area last a. Identify surface characteristics b. Tenderness c. Muscular resistance 3. Rebound tenderness

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a. 4. Deep palpation – ADV technique 5. DO NOT palpate if pt has a rigid abdomen, history of an organ transplant, visible pulsations, or Wilm’s Tumor Liver Palpation (Adv Practice…not normally palpable…maybe if pt is thin) 1. Stands on client’s right side 2. Places right hand at the client’s midclavicular line under and parallel to the costal margin 3. Places left hand under the client’s back at the lower ribs and pressing upward

NUR3138 4. Asks client to inhale and deeply exhale while pressing in and up with the right fingers K. Hooking Technique 1. Have pt take a deep breath 2. Should feel liver’s edge as it drops down on inspiration and rises up on expiration L. Spleen Palpation (Adv Practice…spleen is NOT normally palpable…enlargement or tenderness may result from infection, trauma, or cancer) 1. Stands at client’s right side 2. Places left hand under costovertebral angle and pulls upward 3. Places right hand under the left costal margin 4. Asks client to exhale and presses hands inward to palpate spleen M. Abdominal Pain

1. N. Urinary 1. What is their fx? 2. Normal output: (know these) a. 50-60mL/hour b. 1500-2000mL/day 3. What questions would you ask your patient? a. Frequency? Medications? Blood in urine? Bleeding? 4. Tenderness at costovertebral angle? a. Pain or tenderness is associated with kidney infection or musculoskeletal problems 5. Burning or pain when urinating? 6. Meds? Including OTC 7. Enlarged bladder – where? O. Signs/Symptoms of UTI 1. Burning with urination 2. Strong urge or urinate 3. Can’t urinate very much 4. Strong urine odor 5. Blood in urine 6. Suprapubic pain 7. People with diabetes high/low sugar 8. Cloudy or pink urine

NUR3138 P. Sex 1. What questions? 2. EDUCATION 3. Which wich? a. Chlamydia, gonorrhea, syphilis, herpes, HPV, HIV, trichomoniasis Q. Can STDs Be Spread During Oral Sex? 1. Many STDs, as well as other infections, can be spread through oral sex. Anyone exposed to an infected partner can get an STD in the mouth, throat, genitals, or rectum 2. The risk of getting an STD from oral sex depends on a number of things: a. The particular STD b. The sex acts practiced c. How common the STD is in the population to which the sex partners belong d. The number of specific sex acts performed 3. In general: a. See PPTs R. Early Cancer Warning Signs: 5 Symptoms You Shouldn’t Ignore 1. Unexplained weight loss 2. Fatigue a. Not better with rest 3. Fever a. Especially at night b. Night sweats c. No other s/s of infection 4. Pain a. Doesn’t go away b. Unexplained 5. Skin changes a. Think of skin as a window II. Assessing the Breasts, Axillae, and Regional Lymphatics A. Breast Anatomy 1. Surface anatomy a. Breasts lie anterior to pectoralis major and serratus anterior muscles i. Located between second and sixth ribs, extending from side of sternum to midaxillary line ii. Tail of Spence: superior lateral corner projects up and laterally into axilla b. Areola surrounds nipples c. Montgomery’s Glands: small elevated sebaceous glands i. Secrete protective lipid material during lactation 2. Internal anatomy a. Breast is composed of i. Glandular tissue ii. Fibrous tissue, including suspensory ligaments iii. Adipose tissue

NUR3138 b. Glandular tissue contains 15 to 20 lobes radiating from nipple, and these are composed of lobules c. Cooper’s Ligaments: fibrous bands extending vertically from surface to attach on chest wall muscles d. Lobes are embedded in adipose tissue e. Breast may be divided into four quadrants by imaginary horizontal and vertical lines intersecting at nipple i. Upper outer quadrant is the site of most breast tumors

f. 3. Lymphatics a. Breast has extensive lymphatic drainage b. Four groups of axillary nodes are present i. Central axillary nodes ii. Pectoral (anterior) iii. Subscapular (posterior) iv. Lateral c. From the central axillary nodes, drainage flows up to infraclavicular and supraclavicular nodes B. Developmental Considerations 1. At birth a. Only breast structures present are lactiferous ducts within nipple b. Supernumerary nipple occasionally persists and is visible along track of mammary ridge 2. Adolescence a. Estrogen stimulates breast changes b. Temporary asymmetry i. Occasionally one breast may grow faster than other c. Tanner Staging: i. Five stages of breast development are included as levels of sexual maturity d. Thelarche precedes menarche by about 2 years 3. Pregnancy a. Breast changed begin 2nd month; early sign of pregnancy b. Colostrum may be expressed after 4th month

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Thick yellow fluid is precursor for milk, containing same amount of protein and lactose, but practically no fat ii. Breasts produce colostrum for first few days after delivery iii. Rich in antibodies that protect newborn against infection, so breastfeeding is important 4. Aging Woman – Post Menopause a. ↓ Estrogen; ↓ Progesterone – tissue atrophy b. Decreased breast size makes inner structures more prominent c. A breast lump may have been present for years but is suddenly palpable d. Around nipple, the lactiferous ducts are more palpable and feel firm and stringy because of fibrosis and calcification e. Axillary hair decreases f. Women over 50 years old have increased risk for breast cancer 5. Males a. Examination of male breast can be abbreviated, but do not omit it b. Normal male breast has flat disk of undeveloped breast tissue beneath nipple i. Rudimentary structure consisting of a thin disk of undeveloped tissue underlying nipple ii. Gynecomastia: during adolescence, it is common for breast tissue to temporarily enlarge  Condition is usually unilateral and temporary  Reassurance is necessary for adolescent male, whose attention is riveted on his body image  May reappear in aging male and may be due to testosterone deficiency C. Subjective Data 1. Breast a. Pain, lump, or discharge b. Tash, swelling, trauma c. Hx is breast disease d. Surgery or radiation e. Medications f. Patient-centered care g. Perform breast self-examination/last mammogram 2. Axilla a. Tenderness, lump, or swelling b. Rash 3. Pain a. Any pain or tenderness in breasts? i. Onset b. Pain location i. Localized or diffuse c. Is pain spot sore to touch? Do you feel a burning or pulling sensation? d. Appearance of pain cyclic? i. Any relation to menstrual cycle?

NUR3138 e. Precipitating factors i. Brought on by strenuous activity? ii. Change in activity? iii. Sexual manipulation? 4. Lump, Discharge a. Lump i. Location: Ever noticed lump or thickening in breast? Where? ii. Onset: When did you first notice it? Changed at all since then? iii. Appearance: Does lump have any relation to your menstrual period? iv. Noticed any change in overlying skin:  Redness, warmth, dimpling, swelling? b. Discharge i. Onset: Any discharge from nipple? When did you first notice this? ii. Characteristics:  What color is discharge?  Is consistency thick or runny? Odor? 5. History of Breast Dx a. Any history of breast disease yourself? b. Diagnosis: What type? How was this diagnosed? c. Medical management: When did this occur? How is it being treated? d. Family history: Any breast cancer in your family? Who? Sister, mother, maternal grandmother, maternal aunts, daughter? i. At what age did this relative have breast cancer? D. Subjective Data Questions – Patient-Centered Care 1. Ask about self-breast exam (SBE) a. Teaching moment to review basics of examination 2. Review screening guidelines recommendations based on age and patient history a. American Cancer Society i. Begin at ages 40 to 44, screening mammography ii. Annual mammography from ages 45 to 54 iii. Biennial mammography over age 55 or continuous of annual E. Risk Profile for Breast Cancer 1. Breast cancer is second major cause of death from cancer in women 2. Early detection and improved treatment have increased survival rates 3. Review factors associated with “relative risk” 4. Review statistics of breast cancer morbidity, mortality, and prognosis a. BRCA1 and BRACA2 mutation b. Cumulative risk c. Survival varies by stage when diagnosed. 5. Consider family history, ethnicity, and other environmental variables a. Racial disparity in survival b. Socioeconomic conditions affecting access to health care 6. Screening mammography recommendations 7. Review lifestyle risk factors:

NUR3138 a. Alcohol dose-dependent effect b. Postmenopausal weight gain c. Decreased physical activity F. Inspection of the Breast and Axillae 1. General appearance a. Note symmetry of size and shape b. Common to have a slight asymmetry in size 2. Skin a. Normally smooth and of even color b. Note any areas of redness, bulging, dimpling; and skin lesions or focal vascular pattern c. Fine blue vascular network visible during pregnancy; pale linear striae, or stretch marks following pregnancy d. Normally no edema 3. Lymphatic drainage areas a. Observe axillary and supraclavicular regions; not any bulging, discoloration, or edema 4. Nipple a. Symmetric on same plane on both breasts b. Usually protrude, although some are flat and some inverted c. Normally nipple inversion may be unilateral or bilateral; usually can be pulled out d. Note any dry scaling, any fissure or ulceration, bleeding or other discharge e. Supernumerary nipple is normal variation 5. Check for skin retraction a. Perform sequence of maneuvers to assess for this abnormality b. Signs of retraction i. Dimpling  Nipple retraction ii. Edema (peau d’orange) iii. Fixation iv. Deviation in nipple pointing 6. Examine axillae while woman is sitting a. Inspect skin, noting any rash or infection; lift woman’s arm and support it so that her muscles are loose and relaxed; use right hand to palpate left axilla. b. Reach fingers high into axilla; move them firmly down in four directions. c. Move woman’s arm through range-of-motion to increase surface area you can reach. d. Usually nodes are not palpable, although you may feel a small, soft, nontender node in central group. e. Note any enlarged and tender lymph nodes G. Palpation of the Breasts 1. Vertical strip pattern is recommended to detect for masses a. Two other patterns are in common use: i. From the nipple palpating out to periphery as if following spokes on a wheel ii. Palpating in concentric circles out to periphery 2. In nulliparous women, normal breast tissue feels firm, smooth, and elastic a. Post pregnancy, tissue feels softer and looser

NUR3138 3. Premenstrual engorgement is normal from increasing progesterone 4. After palpating 4 quadrants, palpate nipple; note and induration or subareolar mass a. With your thumb and forefinger, gently depress nipple tissue into well behind areola; tissue should move inward easily 5. If woman reports spontaneous nipple discharge a. Press areola inward with your index finger b. Repeat from a few different directions; note color and consistency of any discharge 6. If report if breast lump, examine unaffected breast first to learn a baseline of normal consistency for this woman H. BSE: Keep Teaching Simple 1. Simpler = compliance 2. Describe correct technique and rationale and expected findings to note as woman inspects her own breasts 3. Teach woman to do this in front of a mirror while disrobed to waist 4. Start palpation in shower, where soap and water assist, then complete lying supine 5. Encourage her to palpate breasts while you monitor technique 6. Use return demonstration and visual aids I. Characteristics of Lump or Mass 1. Location a. As with clock face, describe distance in centimeters from nipple; or diagram breast in woman’s record and mark in location of lump 2. Size a. Judge in centimeters in three dimensions: width, length, and thickness 3. Shape a. State whether lump is oval, round, lobulated, or indistinct 4. Consistency a. State whether lump is soft, firm, or hard 5. Movable a. Is lump freely movable or fixed when you try to slide over chest wall? 6. Distinctness a. Is lump solitary or multiple? 7. Nipple a. Is it displaced or retracted? 8. Note skin over lump a. Is it erythematous, dimpled, or retracted? 9. Tenderness a. Is lump tender to palpation? 10. Lymphadenopathy a. Are any regional lymph nodes palpable? J. Abnormal Findings: Breast Lumps 1. Benign (Fibrocystic) breast disease 2. Cancer 3. Differentiating breast lumps: a. Age

NUR3138 b. Shape, consistency, and demarcation c. Number, mobility, and tenderness d. Skin retraction, pattern of growth, and risk to health 4. Abnormal nipple discharge 5. Disorders occurring during lactation a. Mastitis b. Breast abscess c. Plugged duct 6. Male breast abnormalities a. Gynecomastia b. Male breast cancer III. Assessing the Abdomen A. The Quadrants and Upper, Middle, Lower 1. Right upper quadrant (RUQ) a. Liver b. Gallbladder c. Duodenum d. Head of pancreas e. Right kidney and adrenal gland f. Hepatic flexure of colon g. Part of ascending and transverse colon 2. Left upper quadrant (LUQ) a. Stomach b. Spleen c. Left lobe of liver d. Body of pancreas e. Left kidney and adrenal gland f. Splenic flexure of colon g. Part of transverse and descending colon 3. Right lower quadrant (RLQ) a. Cecum b. Appendix c. Right ovary and tube d. Right ureter e. Right spermatic cord 4. Left lower quadrant (LLQ) a. Part of descending colon b. Sigmoid colon c. Left ovary and tube d. Left ureter e. Left spermatic cord B. Subjective Data 1. What questions will you ask? 2. Appetite: Ask about

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a. changes in appetite—time period and amount. b. changes in weight—loss or gain (amount) and time period. Dysphagia: Ask about a. any difficulty in swallowing. b. onset and associated symptoms. Food intolerance: Ask about a. type of food reaction that occurs. b. use of Rx or OTC medication—amount and frequency. Pain: Ask about a. onset, duration, location and severity. b. characteristics (quality and pattern) and associated symptoms. c. with regard to eating, pain getting worse or better. d. association with any other clinical symptoms. e. alleviating factors and aggravating factors. f. treatment methods: Rx and OTC. Nausea and Vomiting: Ask about a. onset, frequency, type and amount. b. associated symptoms and/or triggers. c. recent foods eaten and/or travel habits. Bowel habits: Ask about a. frequency, color, consistency, diarrhea or constipation. b. any recent changes. c. laxative use—type, amount and frequency. Past abdominal history: Ask about a. GI disease/pathology. b. GI diagnostic procedures. c. GI surgeries and clinical response. Medications: Ask about a. Rx and OTC. b. alcohol—type, amount, and frequency. c. smoking history. Nutritional assessment: Ask about a. dietary history For infants/children: Ask about a. breastfeeding or bottle-feeding. b. tolerating new foods. c. pattern of eating. d. eating of non-foods. e. elimination pattern related to constipation. f. presence of abdominal pain. g. overweight—assess for onset and dietary pattern. For Adolescents: Ask about a. dietary pattern for meals and snacks and calorie consumption. b. exercise pattern.

NUR3138 c. weight status relative to gain or loss. d. determining impact on activity and/or body changes. e. impact of peers and family 13. For Aging Adults: Ask about a. access to groceries and food preparation. b. shared meals or eats alone. c. 24-hour dietary recall. d. swallowing or feeding difficulties. e. activities done following mealtimes. f. bowel health—frequency, constipation, fiber in your diet, use of laxatives. g. medications—Rx and OTC. C. Inspection of the Abdomen 1. Contour a. Determine profile from rib margin to pubic bone; contour described nutritional state and normally ranges from flat to rounded i. Flat ii. Scaphoid iii. Rounded iv. Protuberant 2. Symmetry a. Abdomen should be symmetric bilaterally. 3. Umbilicus a. Normally it is midline and inverted, with no sign of discoloration, inflammation, or hernia. 4. Skin a. Surface smooth and even, with homogeneous color; assess skin turgor b. Inspect for pigment change and presence of lesions or scars. 5. Pulsation or movement a. Normally you may see pulsations from aorta beneath skin in epigastric area, particularly in thin persons with good muscle wall relaxation. 6. Hair distribution a. Pattern of pubic hair growth normally has diamond shape in adult males and an inverted triangle shape in adult females. 7. Demeanor a. A comfortable person is relaxed quietly on examining table and has a benign facial expression and slow, even respirations. D. Auscultation of Bowel Sounds 1. Auscultation is performed NEXT because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds a. Use diaphragm endpiece because bowel sounds are relatively high pitched b. Hold stethoscope lightly against skin; pushing too hard may stimulate more bowel sounds c. Begin in RLQ at ileocecal valve area because bowel sounds are normally always present here

NUR3138 2. Note character and frequency of bowel sounds; Originate from movement of air and fluid through small intestine; High-pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5 to 30 times per minute 3. Abnormal bowel sounds a. Hypoactive: decreased, can follow abdominal surgery or with inflammation b. Hyperactive: loud, high-pit...