Focused Pre Anesthetic Assessment of the GI System
Focused Pre Anesthetic Assessment of the GI System
The gastrointestinal (GI) system performs the functions of ingestion, digestion, and elimination. Interruptions of any of these functions can quickly affect the patient nutritionally and cause acid-base imbalances. When performing the GI assessment, it must be remembered that much of the population has preexisting problems and that these problems can be exacerbated or new conditions can develop when illness in other systems occurs.
A comprehensive gastrointestinal assessment includes history, physical examination and diagnostic tests that provide information about GIT function. However, bedside clinical assessment provides vital information about GIT function. It is important for nurse anesthetists to be able to perform a basic GIT assessment.
If GI symptoms cause the patient pain or discomfort, you will need to move quickly through the assessment. However, any GI complaint must incorporate a health history, even if extremely brief. Assess the following areas in the health history:Pain
Perform a pain assessment to include specific questions about when the pain occurs - before meals, after meals, in the middle of the night, and any food associations. Specifically ask about heartburn and problems with a sore mouth, tongue, or throat.Teeth/Gums
Ask about problems with bleeding gums, dental caries, abscesses, and use of dentures and partial plates. Obtain date of last dental exam and results if possible.Throat
Ask about any hoarseness or voice changes that might indicate the presence of a tumor, any difficulty swallowingAppetite
Assess any changes in appetite, food intolerances, and the presence of nausea and/or vomiting.Lower GI
Assess for problems with eructation, flatulence, hemorrhoids, hernia.
The patient should be questioned about the use of laxatives and antacids and the color, frequency, and amount of stools. Assess previous GI disease history such as cholecystitis, inflammatory bowel disease, or cancer.
Mouth and Throat: Assess the mouth and throat for sores, condition of teeth and gums, irritations, or any other conditions that could affect the intake of food and liquid. Lift the tongue and look under it for any tumors or lesions. Assess for any unusual breath odor.
Abdomen: Inspect for contour, symmetry, abdominal aorta pulsation, and distention. Do not touch the abdomen during the inspection or peristalsis can be stimulated which will provide false data during the auscultation portion of the assessment.
Abdominal Distention Can Be Caused By Three Factors
1. Obesity - Abdomen is soft and rounded with a sunken umbilicus.
2. Ascites - Skin is shiny and glistening with an everted umbilicus. Veins are dilated and prominent (more visible in thin, malnourished skin).
3. Obstruction - There may be visible, marked peristalsis; restlessness; lying with knees flexed; grimacing facial expression; and uneven respirations.
B. AuscultationBowel Sounds
Bowel sounds are best heard with the diaphragm portion of the stethoscope. Note the character (high-pitched, gurgling, clicking, etc.) and frequency. Normally the sounds occur intermittently at 5-15 times per minute. Judge if the sounds are normal, hypoactive or hyperactive. You must listen for 5 minutes to each quadrant before deciding that bowel sounds are absent (20 minutes is unrealistic to expect someone to stand and listen for bowel sounds so we often rely on the patient's other signs and symptoms). If the patient is experiencing an obstruction due to an ileus (absence of peristalsis), bowel sounds will be absent as there is no enervation by the nervous system to the area. If the patient is experiencing a mechanical obstruction (feces, volvulus, tumor, etc.), the bowel sounds can alter between being hyperactive (as the gut tries to push feces around the obstruction) or absent (as the gut rests and prepares for the next peristaltic wave; the patient will also complain of pain when bowel sounds are heard). Peritonitis presents with absent bowel sounds.Vascular sounds
Vascular sounds are best heard with the bell of the stethoscope. Assess all four quadrants listening for bruits (whooshing, blowing sounds that represent impaired circulation within an artery or an aneurysm). An aortic pulsation may be heard over the left upper quadrant in the presence of hypertension, aortic insufficiency, or aortic aneurysm.
Tympani: Tympani should predominate as air rises to surface of the abdominal cavity.
Hyper resonance: Will be heard in the presence of gaseous distention.
Dullness: Percussed over a distended bladder, adipose tissue, fluid, or a mass in the abdomen.
Prior to palpating the abdomen, have the patient bend the knees and relax the abdominal muscles. Ask the patient to point to any painful or tender areas. Save those areas to palpate last so the patient becomes more accustomed to your touch and does not guard throughout the exam. Lightly palpate the abdomen by quadrants. Note any muscle guarding, rigidity, tenderness, or masses.
Rectal Area: Examine the external rectal area for the presence of external hemorrhoids, masses or evidence of inflammation.
History and Physical Examination of the Liver
The symptoms of liver disease are nonspecific. Anorexia, nausea and vomiting, fever and chills, right-upper-quadrant pain, dark urine and light-colored stools, or alteration of taste for cigarettes (suggesting acute hepatitis) may be present. Dry mouth and dry eyes are associated with autoimmune disorders such as primary biliary cirrhosis, and Pruritus develops with intrahepatic cholestasis or extrahepatic biliary blockage. In advanced liver disease, symptoms of confusion and disorientation may indicate hepatic encephalopathy. A history of illicit or prescribed medications, ethanol use, tattoos (especially self-administered), multiple sexual partners, and travel to endemic areas can raise questions of drug-induced or chronic viral hepatitis. Table 1 summarizes signs that may suggest underlying liver disease and associated conditions.
Table 1. Signs of Liver Disease and Related Conditions
|Physical Sign||Possible Condition|
|Jaundice, spider angiomata||Cirrhosis Pregnancy Hyperthyroidism|
|Hyperpigmentation||Primary biliary cirrhosis|
|White nails, clubbing||Cirrhosis|
|Xanthomata, xanthelasma||Primary biliary cirrhosis|
|Obesity, increased waist circumference||Nonalcoholic fatty liver disease|
|Kayser-Fleischer corneal rings||Wilson's disease|
|Parotid enlargement||Alcoholic liver disease|
|Signs of congestive heart failure: jugular venous distention, right pleural effusion, S3 gallop||Cardiac cirrhosis|
|Gynecomastia, testicular atrophy||Cirrhosis|
|Peripheral edema, signs of ascites, hepatosplenomegaly, caput medusa||Cirrhosis|
|Arterial bruit heard over the liver||Hepatocellular carcinoma, alcoholic hepatitis, arteriovenous malformation (rare)|