Gastrointestinal System

Assessment & Diagnostic Studies

Margaret Xaira R. Mercado RN

ASSESSMENT
A. Health History

1. Past health history

2. Medications (past, present, over-the-
counter, herbs)
3. Surgeries
Physical Examination
1. Inspection
a. Mouth – symmetry, color, size, odor, teeth
b. Abdomen – skin changes, symmetry,
contour, masses, movement
1) peristalsis is only visible in a thin adult
2) aortic pulsation may be seen in the
epigastric region
c. Rectum and anus – color, lumps, tissues,
external hemorroids
Physical Examination
2. Auscultation
a. Bowel sounds
1) perform prior to percussion and
palpation
2) auscultate all 4 quadrants
3) high – pitched gurgling occuring every
5 to 15 seconds
4) listen 5 minutes to all four quadrants
before determining absence
b. Aortic bruit indicate turbulent blood flow
Physical Examination
3. Percussion
a. Detrmines pressence of fluid, distention, and
masses
b. Liver 2.4 to 5 inches (6-12 cm) dullness at
the right midclavicular line
c. Tympany predominant sound of the
abdomen
Physical Examination
4. Palpation
a. Mouth – ulcers, indurations, tenderness
b. Abdomen
1) light palpation (1cm) – detects tenderness, masses,
swelling, muscular resistance, cutaneous
hypersensitivity
2) deep palpation (4-6cm) – outlines abdominal
organs and masses
3) round tenderness – indicates peritoneal
inflammation
4) liver – may be felt 0.4 to 0.8 inch (1 to 2 cm)
below the right costal margin
5) spleen – felt only if enlarged, rupture can occur if
continued
DIAGNOSTIC
STUDIES
UPPER GI or
BARIUM SWALLOW
• X-ray study with flouroscopy and contrast
medium (barium)
PREPROCEDURE
1. NPO for 8 to 12 hours
2. No smoking
POSTPROCEDURE
1. Encourage 6 to 8 glasses of water daily
2. Offer laxative – stools may be white for 72
hours
UPPER GI or
BARIUM SWALLOW
LOWER GI or BARIUM ENEMA
• X-ray study visualizing the colon
PREPROCEDURE
a. Day before the test
1) clear liquid for lunch and dinner
2) 8 ounces of fluid every hour for 8 to 10 hours
3) 10 ounces of magnesium citrate or x-prep in mid
to late afternoon
4) prescribed number of 5mg bisacodyl (Dulcolax)
tablets – usually 3 or 4
5) maybe NPO after midnight
LOWER GI or BARIUM ENEMA
b. Day of the test:
1) Bisacodyl (Dulcolax) suppository early morning or tap
water enema
2) continue NPO or clear liquid diet up to the procedure
3) contrast medium (barium) administered rectally
with the client on a tilt table
POSTPROCEDURE
a. Increase fluids
b. Offer laxative – stools may be white for 72
hours
LOWER GI or
BARIUM ENEMA
ORAL CHOLECYSTOGRAM
(GB SERIES)
X-ray visualization of the gallbladder to determine the patency of
the biliary duct system while assessing the ability of the
gallbladder to concentrate, contract and empty
PREPROCEDURE
a. Day before the test:
1) assess for allergy to iodine or seafood
2) evaluate the bilirubin level – if greater than
2mg/dl, will not visualize the gallbladder
3) low-fat or fat-free meal for dinner
4) six radiopaque iopanoic acid (Telepaque)
tablets are administered 5 minutes apart beginning 2 hours
after dinner
ORAL CHOLECYSTOGRAM
(GB SERIES)
5) inform the radiologist if vomiting or
diarrhea occurs after ingestion of the dye
6) NPO after ingestion of the dye

POSTPROCEDURE
a. May be given fatty meal to enhance excretion
of the dye
b. Assess for slight dysuria as the dye is excreted
CHOLANGIOGRAM
X-ray visualization of the hepatic and common bile ducts
PREPROCEDURE
a. Day before the test
1) assess for allergy to iodine or seafood
2) evaluate the bilirubin level – contraindicated if
greater than 3.5 mg/dl
b. Day of the test
1) NPO after midnight
2) radiographic dye is administered
intravenously
CHOLANGIOGRAM
POSTPROCEDURE
a. Two to 6 hours after the test, assess for
delayed reaction to the dye (dyspnea, rashes,
tachycardia, hives)
b. Assess for slight dysuria as the dye is excreted
PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAM
X-ray visualization of the intrahepatic, extrahepatic
billiary ducts and occasionally, the gallbladder
after direct administration of the radiopaque dye
into the intrahepatic duct
Useful in clients who are jaundiced
PREPROCEDURE
a. assess for allergy to iodine or seafood
b. evaluate coagulation studies
c. type and cross match the blood
d. NPO after midnight
PERCUTANEOUS TRANSHEPATIC
CHOLANGIOGRAM
POSTPROCEDURE
a. maintain bed rest for several hours
b. assess for bleeding and sepsis
c. monitor vital signs
d. avoid analgesics to prevent covering up
abdominal signs associated with bile leakage
or hemorrhage
UPPER GI ENDOSCOPY
(Esophagogastroduodenoscopy)
Direct visualization of the upper gastrointestinal
tract using a long, flexible, fiberoptic-lighted
scope
PROCEDURE
a. Day before the test
1) NPO after midnight
2) Remove the client’s dentures and other oral
devices
3) Inform the client that speaking during the
procedure is not possible because of the
fiberscope
UPPER GI ENDOSCOPY
(Esophagogastroduodenoscopy)
b. Day of the test
1) Client is placed on left lateral decubitus position
to facilitate easier insertion of the endoscope
2) Topical anesthetic spray naloxone (Xylocaine) is
applied to the throat to inactive the gag reflex
3) Atropine may be given to reduce secretions
4) Glucagon may be given as a smooth muscle
relaxant
5) Biopsies may be taken if indicated
UPPER GI ENDOSCOPY
(Esophagogastroduodenoscopy)
POSTPROCEDURE
a. Maintain on NPO until gag reflex returns,
usually 2 to 4 hours
b. Assess the gag reflex by tickling the back of
the throat
c. Monitor for signs of perforation (bleeding,
abdominal pain, elevated temperature,
dyspnea, or dysphagia)
d. Offer warm saline gargles or throat lozenges
for relief of sore throat
e. Maintain bed rest with the side rails elevated
until sedation wears off.
UPPER GI ENDOSCOPY
(Esophagogastroduodenoscopy)
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREOTOGRPHY
Radiographic visualization of the common bile
and pancreatic ducts with the use of fiberoptic
endoscope
PREPROCEDURE
a. Day before the test
1) NPO after midnight
2) Inform the client that breathing will not be
compromised with the endoscope
3) Instruct the client that lying very still is
essential to allow for good visualization of the
ducts
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREOTOGRPHY
b. Day of the test
1) Remove the client’s dentures
2) Sedative with narcotic is administered for relaxation
3) Client is placed in supine left lateral position to
facilitate insertion of the endoscope
4) Topical anesthetic spray, naloxone (Xylocaine)
is applied to the pharynx to inactive the gag reflex
5) Place the client in several positions throughout
the procedure to permit passage of a small
catheter into the ductal system for the injection of
radiographic dye so x-ray films may be taken
6)Glucagon is often administered to minimize spasms
and improve visualization of the ampulla of Vater
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREOTOGRPHY
POSTPROCEDURE
a. Maintain NPO until gag reflex returns
b. Monitor for signs of ERCP-induced
pancreatitis (abdominal pain, nausea, and
vomiting)
c. Monitor for signs of ERCP-induced
cholangitis (septicemia)
d. Offer warm saline gergles or throat
e. Maintain bed rest with side rails elevated until
sedation wears off
ENDOSCOPIC RETROGRADE
CHOLANGIOPANCREOTOGRPHY
COLONOSCOPY
Direct visualization of the entire colon from the anus to the cecum
with a flexible fiberoptic scopePD
PREPROCEDURE
a. Day before the test
1)One gallon of GoLYTELY or Colace
administered the evening before the procedure (one glass
every 10 minutes until gone)
2) Bisacodyl (Dulcolax) tablets and enemas may
be given
3) clear liquid diet beginning at noon and up to 8
hours before the procdure, then NPO
COLONOSCOPY
b. Day of the test
1) client is placed in left lateral decubitus position to insert the
colonoscope
2) Administer ordered sedative medication – usually
Midazolam (Versed)
3) Atropine may be given to decrease colonic
secretions
4) Client’s position will be changed to facilitate the
colonoscope as it is directed toward the cecum
COLONOSCOPY
POSTPROCEDURE
a. Maintain bed rest with side rails up until sedation wears off
b. Inform the client that abdominal cramping may be
experienced because air was injected into the colon during the
procedure.
c. Monitor for signs of colon perforation
(abdominal distention and tenderness)
d. Monitor vital signs for signs of hemorrhage
(increased pulse and decreased blood pressure)
e. Offer food after assessing for evidence of
bowel perforation
f. instruct the client to push fluids to compensate
for dehydration from bowel preparation
COLONOSCOPY
PROCTOSIGMOIDOSCOPY
Direct visualization of the anus, rectum, and sigmoid colon with
the use of a fiberscope
PREPROCEDURE
a. Day before the test
1) administer an enema evening before the
procedure
b. Day of the test
1) clear liquid breakfasr
2) administer the enema the morning of the
procedure
3) client is placed in the lateral decubitus
position and assisted into the knee-chest position
during the procedure
PROCTOSIGMOIDOSCOPY
POSTPROCEDURE
a. Inform the client that abdominal discomfort and
flatulence may be experienced because air was
injected into the bowel during the procedure
b. Monitor for signs of rectal bleeding
LIVER BIOPSY
Insertion of a needle between the sixth and seventh or
eighth and ninth intercostal space on the right side
to obtain a specimen for hepatic tissue
PREPROCEDURE
a. Day before the test
1) Obtain the client’s coagulation study (PT,
clotting or bleeding time)
2) type and cross-match
3) Obtain baseline vital signs
4) Obtain informed consent
LIVER BIOPSY
b. Day of the test
1) administer the prescribed sedative
2) place the client in the supine or left lateral
position
3) instruct the client to exhale and hold the
exhalation, allowing the liver to descend,
decreasing the risk of a pneumothorax
LIVER BIOPSY
POSTPROCEDURE
a. Placwe the client on right side for 1-2 hours,
pressing a liver capsule against the chest wall
to decrease risk of hemorrhage
b. Monitor vital signs for evidence of
hemorrhage I increase pulse, decreased blood
pressure) and peritonitis (increased
temperature)
LIVER BIOPSY
GASTRIC ANALYSIS
Contents of the stomach are aspirated to determine the
amount of acid produced during the resting or basal state
(basal acid output [BAO]) and during the stimulated state
(maximal acid output {MAO])
PREPROCEDURE
a. Day before the test
1) instruct the client not to smoke, chew
gum, or take anticholinergic medications
before the procedure
2) NPO after midnight
GASTRIC ANALYSIS
b. Day of the test
1) Nasogastric tube is inserted with syringe
attached to aspirate gastric contents and discard
first specimen
2) four subsequent samples are taken and
analyzed every 15 minutes apart (these are BAO)
3) histamine is administered subcutaneously and
eight samples are taken and analyzed every 15
minutes minutes apart (these are MAO)
4) inform the client that histamine may produce a
flushing sensation
GASTRIC ANALYSIS
POSTPROCEDURE
a. Monitor the client for histamine side effects
such as intestinal, bronchial, and uterine
spasms.
GASTRIC EMPTYING
STUDIES
Radionuclide studies in which the stomach is
scanned until gastric emptying is complete after
the ingestion of the “test meal” either solid or
liquid containing technetium (Tc)

PREPROCEDURE
a. Day before the test
1) NPO after midnight
GASTRIC EMPTYING
STUDIES
a. Day of the test
1) client ingests a solid “test meal” consisting
of a cooked egg white containing Tc or a
liquid “test meal” consisting of a glass of
orange juice containing Tc
2) inform the client that only a small dose of
radionuclear material is ingestedand is safe
3) place the client in a supine position and
images are taken under a gamma camera
every 2 minutes depending on emptying time
GASTRIC EMPTYING
STUDIES
POSTPROCEDURE
a. Instruct the client that no rradiation
precautions need to be taken in the disposal of
bodily secretions
b. Reinforce safety of the dose of the radioactive
material
STOOL SPECIMEN
FECAL FAT – stool is collected continously foe 3
days and fecal fat is measured to evaluate
pressence of malabsorption
PREPROCEDURE
Three day collection
1) 100g of fat ingested per day for 3 days
2) instruct the client to defacate in clean dry
container and to avoid urinating or placing toilet
paper in the container
3) instruct the client to avoid laxatives or
enemas during the test
STOOL SPECIMEN
4) send each stool specimen to the lab
immediately in an acute care setting, or
instruct the client to keep all stool container in
the freezer at home until completion of the test
POSTPROCEDURE
1) Instruct the client to resume a normal diet
STOOL SPECIMEN
OCCULT BLOOD – stool sample is obtained to determine
presence of gastrointestinal bleeding
PREPROCEDURE
1) Instruct the client to avoid red meats, raw vegetables,
fruits and vitamin C for 3 days before the test
2) instruct the client to avoid taking
nonsteroidal anti-inflammatory drugs,
anticoagulants, and steroids for 7 days before the
test
3) instruct the client to defacate in an
appropriate container, keeping the stool specimen
free from urine or toilet paper
Types of tests for
occult blood
HEMOCULT TEST
1) Open the front cover of the Hemoccult slide and
apply a thin smear of stool
2) open the back cover of the Hemoccult slide and
apply two drops of developer on the slide
3) bluish discoloration indicates presence of occult
blood
Types of tests for
occult blood
HEMATEST
1) place a small smear of stool on the guiac
filter paper
2) put a Hematest tablet in the middle of the
stool sample
3) place 2 or 3 drops of water on the tablet
4) bluish discolorration indicates pressence of
occult blood
STOOL FOR OCCULT BLOOD
POSTPROCEDURE
a. Resume normal diet and medications
STOOL CULTURE – stool sample is obtained to determine
presence of a bowel infection
PROCEDURE
1) Instruct the client not to void urine with stool
sample
2) Dip a sterile swab into the purulent fecal matter
and then place the swab in a sterile test tube
3) Send the specimen immediately to the lab
UREA BREATH TEST
Breath sample taken after ingestion of carbon – labeled urea
capsule to determine presence of Helicobacter pylori
PREPROCEDURE
a. Instruct the client to avoid loperamide (Pepto-Bismol) and
antibiotics for 1 month prior to the test
b. Instruct the client to avoid omeprazole
(Prilosec), lansoprazole (Prevacid), or
esomeprazole (Nexium) for 1 week
c. Instruct the client to avoid nizatidine (Axid),
ranitidine (Zantac), famotidine (Pepcid), or cimetidine
(Tagamet) for 24 hours prior to the test
UREA BREATH TEST
PROCEDURE
a. Client ingests a carbon labeled urea capsule
b. Breath sample is taken 10-20 minutes later
PARACENTESIS
Insertion of a needle into the peritoneal cavity to remove ascitic
fluid
PREPROCEDURE
a. Instruct the client to empty the bladder (prevents accidental
trauma from the needle during the provedure)
b. Measure the abdominal girth
c. Obtain the client’s weight
d. Obtain baseline vital signs
e. Place the client in a high-Fowler’s position in the
bed or in a chair with the back supported and feet flat
on a stool
PARACENTESIS
POSTPROCEDURE
a. Monitor vital signs
b. Measure and compare preprocedure weight
and abdominal girth
c. Monitor serum protein and electrolyte levels
because of high albumin and electrolytes,
especially sodium
d. Monitor dressing over the needle puncture site
for bleeding
PARACENTESIS
• Elevated in biliary obstruction or extensive liver disease
Cholesterol
• Decreased in acute pancreatitis or malabsorption syndrome
Calcium
• Elevated in biliary obstruction or impaired liver function
Bilirubin
• Elevated in acute pancreatitis
Amylase
• Elevated in severe liver disease
Ammonia
• Decreased in chronic liver disease or malabsorption
Albumin
BLOOD CHEMISTRIES
• Elevated in cirrhosis Protein
• Decreased in other liver disease or malabsorption
• Decreased in severe diarrhea, vomiting, starvation, fistula Potassium
along GI tract, or pyloric obstruction
• Elevated in biliary obstruction
Phosphatase, Alkaline
• Elevated in acute pancreatitis, liver disease, or perforated Lipase
peptic ulcer
(LDH)
• Elevated in metastatic cancer of the liver Lactic Dehydrogenase
• Elevated in pancreatic insufficiency
• Decreased in pancreatic hypofunction, tumor, or dumping
Glucose (fasting)
syndrome
BLOOD CHEMISTRIES
• Decreased in pernicious anemia or after gastrectomy
Vitamin B12
• Decreased in malnutrition or severe liver damage
Urea Nitrogen (BUN)
• Elevated in liver disease Triglycerides
• Decreased in malnutrition
Aminotransferase (ALT)
• Elevated in liver disease Serum Glutamate Pyruvate (SGPT) Alanine
Aspartate Aminotransferase (AST)
• Elevated in acute hepatitis Serum Glutamicoxaloacetic (SGOT) or
Sodium
• Decreased in severe diarrhea or vomiting
BLOOD CHEMISTRIES