Assessment & Reasoning GI System Peggy Scott, 48 years old Suggested GI/GU Nursing Assessment Skills to Be Demonstrated: GI/GU: Inspection: skin (coloration, vascularity, striae, scars, lesions, rashes) • Contour from 2 angles – (flat, rounded, scaphoid, protuberant/distended) • Note symmetry, color, veins, lesions, scars, hair distribution • Umbilicus – contour; Note: inguineal or umbilical hernias • Symmetry (relaxed, supine position) • Abdominal movement during breathing • Aortic pulsations Auscultation: (completed before palpation/percussion to not alter bowel sounds) • Bowel sounds – 1 minute per quadrant up to 5 minutes with the diaphragm • Intensity, pitch, frequency • Vascular sounds – listen for bruits in abdominal aorta with bell. Palpation: • Light palpation to all quadrants – 1 to 2 cm to detect tenderness • Deep palpation to all quadrants – 5 to 6 cm for masses (location, size, shape, pulsatility, mobility, tenderness) • Palpate bladder- light palpation ONLY; you only want to assess to see if it is distended • Check for costovertebral angle tenderness Make Learning Active! • Role play or go through the interview/body assessment process – student to student or as a group. • Review the case study as an application exercise in small groups or together as a class. • Depending on your program, some content in the case study may not have been taught. Do not let that prevent you from utilizing this case study! Use it to promote learning by having students identify what they do not yet know and guide where they can find the information in the textbook or on the internet to address knowledge gaps. This is educational best practice and another way to scaffold knowledge! Copyright © 2019 Keith Rischer, d/b/a KeithRN. All Rights reserved. Present Problem: Peggy Scott is a 48-year old African American woman who came to the emergency department because she is having severe abdominal pain radiating to the back that started 24 hours ago but has become progressively worse in the last couple of hours. She is now nauseated and states that she has “puked small amounts of green liquid” five times in the last four hours. She had two loose stools today that were dark brown or black in color. Peggy has struggled with ETOH use/abuse most of her adult life but has been sober the past six months. She begins to cry and tells the nurse that this week was the one-year anniversary of her only son’s death in an automobile accident. She reports that she has been drinking one liter of vodka daily the past week. What data from the present problem are RELEVANT and must be interpreted as clinically significant by the nurse? (Reduction of Risk Potential) RELEVANT Data from Present Problem: Clinical Significance: Severe abdominal pain radiating to the back. Began 24 hours ago and is worsening. Nauseous Puked green liquid 5x. 2 loose stool dark brown/black Crying about sons death - Constant pain in your upper belly that radiates to your back. This is a symptom of pancreatitis. -Nausea from alcohol intake which increases the production of stomach acids and delays the stomach from emptying. Also signs of pancreatitis. -Green/yellow vomit could indicate bile produced by the gallbladder. -Brown stool is normal but black would indicate bleeding in the GI tract iron/ something she ate What is the RELATIONSHIP of your patient’s past medical history (PMH) and current meds? (Which medication treats which condition? Draw lines to connect.) PMH: Home Meds: Pharm. Class: Mechanism of Action (own words): • Depression • Low back pain • Ibuprofen 600 mg PO three times daily PRN • Citalopram 40 mg PO daily NSAID nonsteroidal anti-inflammatory drugs SSRI serotoninreuptake inhibitors IBUPROFEN- reduces pain and inflammation in the body. • Pancreatitis Citalopram- used for depression (no current meds) • ETOH abuse (no current meds) Patient Care Begins: Current VS: P-Q-R-S-T Pain Assessment: T: 100.6 F/38.1 C (oral) Provoking/Palliative: Movement provokes, nothing relieves pain P: 98 (regular) Quality: Sharp R: 20 (regular) Region/Radiation: Epigastric area/LUQ BP: 146/94 Severity: 10/10 O2 sat: 95% room air Timing: Continuous since onset 24 hours ago What vital signs are abnormal? What is the reason (pathophysiology) for these findings? (Reduction of Risk Potential/Health Promotion and Maintenance) Abnormal VS: Clinical Significance: T: 100.6 oral temp -High fever likely caused due to pancreatitis P: 98 -Although this is within normal limits it is borderline to tachycardia likely caused by pain level R: 20 hypovolemia BP: 146/94 -Although this is technically normal it is borderline Tachypnea likely caused by current sitation, pain level -High bp could be a result of pain level and alcohol intake Current Assessment: GENERAL SURVEY: Alert, oriented, pleasant, in no acute distress, Is unkept in appearance with soiled clothing, body tense, grimacing NEUROLOGICAL: Alert & oriented to person, place, time, and situation (x4) HEENT: Head normocephalic with symmetry of all facial features. PERRLA, sclera white bilaterally, conjunctival sac pink bilaterally. Lips, tongue, and oral mucosa pink and tacky dry in appearance. RESPIRATORY: Breath sounds clear with equal aeration on inspiration and expiration in all lobes anteriorly, posteriorly, and laterally, nonlabored respiratory effort on room air. CARDIAC: Pink, warm & dry, no edema, heart sounds regular, pulses strong, equal with palpation at radial/pedal/post-tibial landmarks, brisk cap refill. Heart tones audible and regular, S1 and S2, noted over A-P-T-M cardiac landmarks with no abnormal beats or murmurs. No JVD noted at 30-45 degrees. ABDOMEN: Abdomen round, soft, and tender in epigastric area and LUQ to gentle palpation. Nauseated with small light bile green emesis, BS + in all four quadrants GU: Voiding without difficulty, urine dark amber INTEGUMENTARY: Skin warm, dry, intact, normal color for ethnicity. No clubbing of nails, cap refill <3>