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Head-to-Toe Assessment: Abdominal / Gastrointestinal Assessment

Checklist 19 provides a guide for subjective and objective data collection in an abdominal /  gastrointestinal assessment.

Checklist 19: Abdominal / Gastrointestinal Assessment

Figure 2.18 GI system
Disclaimer: Always review and follow your agency policy and guidelines regarding this specific skill.
 
Safety considerations:
  • Perform hand hygiene.
  • Introduce yourself to patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain process to patient.
  • Be organized and systematic in your assessment.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.

Objective Data

Consider the following observations:

Steps

Additional information
Overall Appearance: Observe for abdominal distension, stretch marks, contour, symmetry, presence and type of ostomy, overweight or underweight. 
Figure 2.20 Ileostomy bag
Figure 2.19 Abdominal distension
 Abdominal distension may indicate ascites associated with conditions such as heart failure, cirrhosis, cancer, and pancreatitis.  An abdomen that appears thin with little adipose tissue might suggest nutrition issues. It is important for the nurse to ask “is this normal for your abdomen” to help differentiate patient “norm” to signs and symptoms that may indicate an acute issue. Unusual findings may indicate compromised GI function.  
Auscultate Bowel Sounds   
Auscultate for bowel sounds
Figure 2.21 Abdominal quadrants
 Divide the abdomen into quarters. Auscultate in each quadrant for evidence of gurgling, which suggests peristalsis.  Hyperactive bowel sounds may indicate bowel obstruction, gastroenteritis, or subsiding paralytic ileus. Hypoactive or absent bowel sounds may be present after GI surgery or when peritonitis or paralytic ileus are present.
Palpate Lightly in All Four Quadrants for Distension, Firmness, Masses, Pain  Firmness may indicate excess gas, ascites, peritonitis. Always ask the patient “is this normal for you?”
Observe stool to identify important characteristics. Sometimes observing stool is an important part of the assessment process. Characteristics of bowel movements can assist with diagnosis and to help determine effectiveness of treatment for bowel related conditions.    Resource: Bladder and Bowel Foundation (nd).  Bristol Stool Chart.  https://www.bladderandbowel.org/wp-content/uploads/2017/05/BBC002_Bristol-Stool-Chart-Jan-2016.pdf
 
Subjective Data
  • Ask about last bowel movements and normal bowel patterns. Changes to bowel patterns may indicate a larger GI issue. Normal bowel patterns vary across individuals. Knowing what is normal will help the nurse differentiate if there is a new or emergent concern requiring attention.
  • Ask about flatus, nausea, vomiting, and pain. Any of these may be symptoms of a GI issue.
  • Ask about dietary habits. What kinds of foods does the patient normally eat? Has this changed?
  • Ask about recent weight gain or weight loss. Unexplained weight loss or weight gain may indicate a larger issue and may need investigation. In the surgical context, significant weight loss can result in delayed wound healing and risk of wound dehiscence.
Focused GI assessment may also include ostomy assessment. See Chapter 11: Ostomy Care
Potential GI related nursing diagnoses: 
  • Need for information in relation to low fat foods.
  • Alteration in bowel function (constipation or diarrhea) related to ….
  • Potential for delayed wound healing due to altered nutrition status (10 kg unexplained weight loss in 1 month)
  • Alteration in dietary intake secondary to slowed GI function post op
Data sources: Assessment Skill Checklist, 2014; Jarvis, Browne, MacDonald-Jenkins, & Luctkar-Flude, 2014; Potter et al., 2019; Stephen, Skillen, Day, & Jensen, 2012; Wilson & Giddens, 2013

Critical Thinking Exercises

  1. A patient who experiences intermittent constipation asks what they might do to promote bowel regularity. Describe three nursing interventions that the nurse might discuss.
  2. Describe the character of stool expected from an ileostomy.

Attributions:

Figure 2.18 Gastrointestinal Tract by Mariana Ruiz, Jmarchn is in the public domain. Figure 2.19 Big Man Big Stomach by Mike Baird is used under a CC BY 2.0 license. Figure 2.20 Ileostomy with Bag by Remedios44 is used under a Creative Commons Attribution-Share Alike 4.0 International license. Figure 2.21 Abdominopelvic Quadrants by Bruce Blaus is used under a Creative Commons Attribution 3.0 Unported license. 


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