Health Alterations IIManagement of Clients

with Problems of the Gastrointestinal SystemLecture 1.Lecture 1.Asessment of the Asessment of the Gastrointestinal, Biliary, and Gastrointestinal, Biliary, and Exocrine Pancreatic SystemsExocrine Pancreatic Systems

The gastrointestinal (GI) system, also termed the digestive system and alimentary canal, consists of the GI tract and its accessory organs.Its primary function is to convert ingested nutrients and fluids into a form that can be used by the cells of the body. This goal is accomplished through the processes of ingestion, digestion, and absorption.The second major function of the GI system is the storage and final excretion of the solid waste products of digestion. Proper functioning of the GI system is essential to the maintenance of proper nutrition and health

ANATOMY AND PHYSIOLOGY The upper portion of the GI tract consists of those structures that aid in the ingestion and digestion of food. These structures include the mouth, esophagus, stomach, and duodenum, plus the related organs of the biliary system and exocrine pancreas. The lower GI tract consists of the small and large intestines, the rectum, and the anus.

The GI system is primarily composed of a hollow, muscular tube approximately 9 m (30 feet) long that stretches from the mouth to the anus.Although this muscular tube is located within the body, it is actually an extension of the external environment. The walls of the GI tract successfully prevent most harmful agents from entering the body and essential body fluids and materials from leaving the body. The composition of the walls is predominantly smooth muscle; however, the mouth and upper esophagus, along with a portion of the rectum and anus, consist of voluntary muscle.

I. MouthThe mouth is made up of the lips, cheeks, tongue, hard and soft palates, teeth, and salivary glands. These structures begin the digestive process by mechanically breaking down and lubricating the food. Because digestive enzymes can function only on the exposed surfaces of food particles, the teeth must begin the breakdown of food. No other portion of the GI system can perform the function of the teeth in their absence.The lubrication of food is accomplished by the action of the watery and mucous secretions of the salivary, parotid, sublingual, and submandibular glands of the mouth. Saliva also contains ptyalin (amylase), which hydrolyzes starch to maltose. Small amounts of saliva, which contain immunoglobulin A (IgA) antibodies to many normal environmental microorganisms, are produced continually to keep the tissues of the mouth moist and clean. After chewing and moistening are completed, the muscular tongue pushes the food bolus back to the pharynx to initiate swallowing (deglutition).

II. Esophagus The esophagus begins at the lower end of the pharynx. It is a hollow, muscular tube 10 inches (25 cm) in length that lies be hind the trachea, passes through the thorax, and connects the mouth and stomach. The upper third is composed of skeletal muscle, and the lower two thirds are smooth muscle. Both ends of the esophagus are protected by sphincters that help prevent the reflux of gastric contents. Both sphincters are normally closed, except during the act of swallowing. The primary function of the esophagus is to move the food bolus by peristalsis from the pharynx to the stomach. No enzymes are secreted by the esophagus, and only mechanical digestion takes place. The secretion of mucus assists in the movement of the food bolus and protects the walls of the esophagus from abrasion by partially digested food.Swallowing is a complex physiologic mechanism that must be accomplished without compromising respiration. It consists of three phases: (1) the voluntary phase, in which the tongue forces the bolus of food into the pharynx; (2) the involuntary pharyngeal phase, in which the food moves into the upper esophagus; and (3) the esophageal phase, during which food moves down into the stomach. The esophageal muscles are activated by the glossopharyngeal and vagal nerves, which create rhythmic peristaltic waves that propel the food toward the stomach. Food is prevented from passing into the trachea by the closing of the epiglottis and the opening of the esophagus.

III. Stomach The stomach is roughly J shaped and lies in the upper abdomen to the left of midline. It is positioned to the left of the liver, to the right of the spleen, and posterior to both organs. It is a muscular pouch whose shape changes with its contents. Its three major regions are the fundus, body, and antrum. The cardiac sphincter protects the opening from the esophagus, and the pyloric sphincter protects the exit to the duodenum. The rugae, or longitudinal folds, of the stomach enable it to quadruple in size and increase from a resting volume of 50 ml to a capacity of approximately 1500 ml for food digestion without major changes in pressure. The stomach has an outer serous layer and three layers of smooth muscle. The outermost layer of smooth muscle is longitudinal, the middle layer is circular, and the inner layer is oblique. The rugae are found on the inner mucosal layer.

The stomach primarily serves as a reservoir but also has digestive and secretory functions. Food is stored in the stomach until partially digested. The fundus contains chief cells, which secrete digestive enzymes, and parietal cells, which secrete water, hydrochloric acid (HCL), and the intrinsic factor that is essential for the absorption of vitamin B12. The HCL is responsible for the highly acidic medium of the stomach (pH of 0.9 to 1.5), which is needed to activate the enzymes that initiate protein digestion. This highly acidic pH also serves as a protective barrier, destroying most ingested microorganisms. Gastric acid secretion is under the control of parasympathetic stimulation via the vagus, as is the secretion of gastrin and histamine. Gastrin is a hormone secreted from endocrine cells in the gastric glands of the stomach in response to vagal stimulation and mechanical distention of the stomach. The secretion of histamine 2 (H2) also increases gastric acid secretion. Approximately 2 to 2.5 l of gastric secretions are produced each day.

The gastric mucosa is covered by a thick mucous gel layer produced by the densely packed epithelial cells of the mucosa. The mucous layer is almost completely impermeable to hydrogen ions. The mucosal epithelial cells also secrete bicarbonate, which acts as a buffer and helps neutralize the acidic secretions. The combined actions of these two mechanisms are so effective that, although the gastric secretions have a pH of less than 2.0, the intraluminal pH of the mucosa is maintained at about 7.0.Gastric emptying is controlled by both hormonal and autonomic nervous system activity. Parasympathetic stimulation, by the vagus nerve increases both peristalsis and secretion. Sympathetic stimulation inhibits them. The peristaltic contractions of the stomach propel the chyme toward the antrum and occur at a frequency of about three to five contractions per minute. The pylorus closes during antral contraction, and larger food particles are propelled back toward the body of the stomach for further mixing. Gastric contents are emptied into the duodenum between peristaltic contractions. Although the pylorus is not a true anatomic sphincter, it does help prevent the backflow of duodenal contents and bile salts into the stomach.

IV. Gallbladder and Biliary Ductal System The gallbladder is a pear-shaped organ that lies on the inferior surface of the liver. It is composed of serous, muscular, and mucus layers and has a usual capacity of 50 ml, although it can increase in size under normal conditions. Innervation of the gallbladder is from the parasympathetic and sympathetic nervous system. The cystic duct connects the gallbladder with the remaining structures of the ductal system — the hepatic ducts and common bile duct.The major function of the gallbladder is to store and concentrate bile. Bile, which is formed in the liver, is excreted into the hepatic ducts, which unite to form the common bile duct. It passes behind the pancreas, is joined by the pancreatic duct, and empties into the duodenum. The sphincter of Oddi regulates the flow of bile into the duodenum. A second sphincter is located above the junction with the pancreatic duct and controls the flow of bile in the common bile duct. When this sphincter is closed, bile moves back into the gallbladder, where it is concentrated fivefold to tenfold. Because bile can be released directly into the duodenum from the liver, the gallbladder is not essential to life. Bile salts facilitate fat digestion by emulsifying fats for action by intestinal lipases and facilitate the absorption of fats, fat-soluble vitamins, and cholesterol.

The release of bile from the gallbladder or liver is controlled by cholecystokinin (CCK). Approximately 600 to 800 ml of bile is produced daily. CCK is released from the walls of the duodenal intestinal mucosa when lipids, amino acids, and hydrogen ions enter the duodenum from the stomach. It travels via the blood to the gallbladder and causes contraction of the gallbladder's smooth musculature and relaxation of the sphincter at the end of the common bile duct (the sphincter of Oddi), so that bile can be emptied into the duodenum.Most of the bile salts are reabsorbed from the intestine into the enterohepatic circulation and returned to the liver, where they can be recirculated. The system is so efficient that only 15% to 25% of the bile salt pool needs to be replaced by the liver each day.

V. Pancreas The pancreas is an elongated, flattened organ located in the posterior abdomen, with its head lying within the curve of the duodenum and its tail resting against the spleen. The pancreas has both exocrine and endocrine functions. The exocrine functions are carried out by the acini cells and duct system, and the endocrine functions are carried out by islets of Langerhans cells.

The pancreas is divided into three parts, which are composed of lobules. The lobules are formed from groups of secretory cells termed acini, which drain into a ductal system that ultimately reaches the main pancreatic duct of Wirsung. This major duct extends the entire length of the gland. At the head of the pancreas the ductal secretions enter the duodenum through the ampulla of Vater. The sphincter of Oddi controls its opening. Approximately 2 l of pancreatic secretions are produced daily. The ductal epithelium produces a balanced electrolyte secretion, and the acini secrete digestive enzymes in an inactive precursor state. The pancreatic secretions contain trypsin, a proteolytic enzyme, which breaks down protein; pancreatic amylase, which breaks down starch; and lipase, which hydrolyzes fat into glycerol and fatty acids. The pancreatic acini also produce an enzyme inhibitor that prevents the activation of the secretions before they reach the duodenum. The production of the pancreatic secretions is controlled by the action of the parasympathetic nervous system, gastrin, and hormones released from the duodenum during digestion.

VI. Intestines The small intestine is about 2.5 cm (1 inch) wide and 6 m (20 feet) long and fills most of the abdomen. It consists of three parts: (1) the duodenum that connects to the stomach, (2) the jejunum, or middle portion, and (3) the ileum that connects to the large intestine (see Figure 31-1).The large intestine is about 6 cm (2.5 inches) wide and 1.5 m (5 feet) long. It also consists of three parts: (1) the cecum that connects to the small intestine, (2) the colon, and (3) the rectum. The ileocecal valve prevents backward flow of fecal contents from the large intestine to the small intestine. The vermiform appendix, which has no known function, is an appendage close to the ileocecal valve. The colon is subdivided into four sections: the ascending, transverse, descending, and sigmoid colons. The points at which the colon changes direction are named for adjacent organs: the liver (hepatic flexure) and the spleen (splenic flexure). The rectum is 17 to 20 cm (7 to 8 inches) long, ending in the 2- to 3-cm anal canal. The opening of the anus is controlled by a smooth muscle internal sphincter and a striated muscle external sphincter.

VI.I. Small IntestineThe primary functions of the small intestine are the digestion of food and the absorption of nutrients. This process occurs primarily in the jejunum and ileum. The duodenum contains the opening for the bile and pancreatic ducts, which allow bile and pancreatic secretions to enter the intestine. Mucus-producing glands are concentrated where gastric contents are emptied and digestive secretions enter the duodenum. The mucus helps protect the duodenum from the acids in the gastric chyme and the actions of the digestive enzymes.Digestion begins in the mouth and stomach, but it takes place primarily in the small intestine. The intestinal mucosa is impermeable to most large molecules, so proteins, fats, and complex carbohydrates must be broken down into small particles before they can be absorbed. The intestinal mucosa also secretes surface enzymes that aid in digestion and about 2 l/day of serous fluid that acts as a diluting agent to facilitate absorption.Carbohydrate digestion, which begins in the mouth, is completed in the small intestine as disaccharides are broken down into monosaccharides (glucose, fructose, and galactose) by the action of intestinal enzymes and pancreatic amylase. Protein digestion, which begins in the stomach, is completed as polypeptides are broken down into peptides and amino acids by the action of pancreatic trypsin. Fat digestion is accomplished by emulsification into small droplets by the action of bile and pancreatic lipase. The droplets are then further broken down into glycerol and fatty acids. The release of digestive secretions is stimulated by the hormones secretin and CCK (also called pancreozymin), as well as by the action of the parasympathetic nervous system.

The inner mucosal surface of the small intestine is covered with millions of villi, which are the functional units for absorption. Each villus is equipped with a blind-end lymph vessel (lacteal) in its center, which is surrounded by capillaries, venules, and arterioles. These structures bring blood to the surface of the intestine and provide a network for absorption into the portal blood or lymphatic system. Ninety percent of absorption occurs within the small intestine by either active transport or diffusion. Active transport requires a metabolic energy expenditure and is used to absorb amino acids, monosaccharides, sodium, and calcium. Fatty acids and water diffuse passively, primarily into the lymphatics.

The contents of the small intestine (chyme) are propelled toward the anus by regular peristaltic movements. Both segmental and propulsive movements occur. The segmental movements involve primarily the circular muscles of the intestine. Slow contractions move the chyme back and forth in small segments of the intestine (1 to 4 cm). This movement mixes the chyme and facilitates digestion and absorption. Segmental peristaltic movements increase after meals. The propulsive peristaltic movements involve intestinal segments 10 to 20 cm long. Contraction occurs in the proximal segment, with relaxation in the distal segment. Chyme advances slowly and normally takes 3 to 10 hours to move from the stomach to the colon. Parasympathetic stimulation, primarily through branches of the vagus nerve, increases peristaltic activity. Sympathetic stimulation is primarily inhibitory.

VI.II. Large Intestine Minimal chemical digestion takes place in the large intestine. It functions primarily to absorb water and electrolytes from the chyme and store the food waste (feces) until defecation. Reabsorption occurs predominantly in the right or ascending colon. The colon can absorb six to eight times more fluid than is delivered to it daily, and only approximately 100 ml of fluid is left in the colon to be mixed with the fecal residue. The large number of microorganisms found in the large intestine further break down the residual proteins that were not digested or absorbed in the small intestine. The breakdown of amino acids produces ammonia, which is converted to urea by the liver. These intestinal bacteria also play a vital role in the synthesis of vitamin K and some of the B vitamins. The only significant secretion of the colon is mucus, which protects the walls and helps the fecal matter adhere into a mass.Approximately 450 ml of chyme reaches the cecum each day. The transit time in the large bowel is slow, taking about 12 hours to reach the rectum. The fecal contents in the colon are pushed forward by mass movements that occur only a few times each day. These mass movements are stimulated by gastrocolic reflexes initiated when food enters the duodenum from the stomach, especially after the first meal of the day.The rectum is well innervated with sensory fibers. Parasympathetic fibers are responsible for the contraction of the rectum and relaxation of the internal sphincter of the anus. The defecation reflex occurs when feces enter the rectum. Afferent impulses are transmitted to the sacral segments of the spinal cord; subsequently, reflex impulses are transmitted back to the sigmoid and rectum, initiating relaxation of the internal anal sphincter.

VII. Physiologic Changes With Aging Gastrointestinal complaints are extremely common in elderly persons. Distinct changes occur in the GI system with aging, although these changes are incompletely understood. Although most of the aging-related changes do not interfere with normal functioning, it is important for nurses to be cognizant of the changes and incorporate appropriate modifications when planning care for elders. In addition, the GI effects of other chronic illnesses such as diabetes require careful con sideration because they are usually more important than the effects of aging itself.In the mouth, teeth darken and may loosen or fracture, and the gums recede. Salivary gland output decreases, which causes mouth dryness and increased susceptibility to infection and tissue breakdown. Aging causes decreased motility and strength of peristalsis in the esophagus, but these changes appear to have minimal significance in healthy persons. Some deterioration in the lower esophageal sphincter may increase the frequency of esophageal reflux.Gastric motility and emptying diminish slightly but progressively with age, and gastric acid secretion also decreases steadily after age 50. Achlorhydria (absence of free HC1) is relatively common. These changes can produce minor problems in digestion but are usually asymptomatic. Chronic gastritis is common in elderly persons, but the condition is usually the result of bacterial colonization by Helicobacter pylori and not aging.

No significant changes in biliary system morphology are associated with aging. However, the composition of the bile becomes increasingly lithogenic (likely to produce calculi), possibly related to an increase in biliary cholesterol; therefore the incidence of gallstones increases with each decade.The pancreas exhibits ductal hyperplasia and fibrosis with aging, but these changes are not necessarily associated with altered functioning. The output of pancreatic secretions steadily declines after age 40, but related problems with absorption have not been documented.Age-related changes in small intestinal function are important and can lead to poor nutrition even with adequate intake. Nutrient absorption is impaired, particularly the absorption of carbohydrates. Absorption of water-soluble vitamins remains intact, but the absorption of vitamin D is defective in many elderly persons, and the active transport of calcium is also impaired. Decreased production of secretory IgA can lead to an increase in the frequency and severity of infections.Chronic constipation is one of the most common complaints in elderly persons. Yet the segmental mass movements and contractions of the large intestine have been found to be unchanged as long as the individual remains physically active. The incidence of both diverticula and polyps in the colon increases with age. There is a decrease in elasticity in the rectum and a steady decrease in the rectal volume, which can result in sphincter failure. However, the sensation of rectal fullness remains intact, and most problems with bowel incontinence in elderly persons are not attributable to the effects of aging.

HEALTH HISTORY A thorough health history is necessary to adequately assess the health status of persons with potential dysfunction of the GI system.

I. Patient/Family History The nurse asks the patient about previous GI problems, hospitalizations, and surgeries. This includes past and current medication use, both over-the-counter and prescribed. The use of antacids and laxatives is particularly important. The nurse inquires about the presence of GI problems in the nuclear or extended family, including cancer and disorders such as inflammatory bowel disease, which have a documented hereditary link.

II. Diet and Nutrition The adequacy of the diet, in terms of both quality and quantity, can be quickly estimated through comparison of the diet with recommended food intake patterns. Nutritional assessment has particular significance in GI disorders, because it may reveal changes in eating patterns characteristic of specific illnesses or disorders. The nutritional assessment includes an exploration of usual eating patterns and any changes that may be the result of illness or specific symptoms. The assessment explores changes in appetite, food preferences and intolerances, food allergies, planned and unplanned changes in weight, adherence to special or therapeutic diets, and the use of dietary or vitamin supplements. A 24-hour dietary recall may be a useful tool to approximate caloric and specific nutrient intake and analyze the overall adequacy of the diet. Symptoms related to food intake should also be carefully assessed. Changes in appetite and the presence of such symptoms as dysphagia, nausea, and discomfort are carefully explored.Lifestyle, economic, and cultural factors affecting nutrition are also assessed. Food has multiple social and emotional values for individuals that are distinct from its role in nutrition. Financial resources, access to food preparation and storage facilities, and religious or social beliefs may all influence both the quality and quantity of the diet. Lifestyle factors can have a direct or indirect effect on GI function. Gastrointestinal symptoms commonly develop or worsen in response to life stressors. Open-ended questions are most effective for exploring beliefs and feelings about food.A complete nutritional assessment includes an evaluation of the patient's use of sugar and salt substitutes, coffee, alcohol, and tobacco (both chewing and smoking). The presence of dentures is an essential consideration because dentures may significantly influence food selection and chewing.

III. Abdominal Pain Although pain is not an early or common manifestation of GI disease, it is frequently the reason individuals seek medical attention. The nurse assesses its onset, duration, character, location, and relationship to meals, stressful events, activity, or medications. The patient is asked to point to the site of pain in the abdomen. Pain may be experienced anywhere along the length of the GI tract in a specific localized pattern, a general nonspecific pattern, or referred to another somatic or skeletal region that shares the same nerve innervation. Abdominal pain may be continuous, episodic, or associated with eating. The pain sensation is thought to arise from the distention or sudden contraction of a hollow viscus; therefore, local stretching or traction on pain-sensitive structures will elicit the pain stimulus. The painful area may exhibit local muscle guarding, which serves as a protective mechanism. The pain associated with pancreatic or biliary dysfunction is usually severe.

Common Sites of Reffered Pain

IV. Food Intolerance Abdominal pain or discomfort may also be reported as heart burn, indigestion, belching, or bloating and requires further clarification. The discomfort may interfere with chewing or swallowing food. Specific foods, such as those that are spicy, very hot, or very cold, may precipitate the discomfort; smoking and/or alcohol consumption may also trigger abdominal discomfort. The patient may have already self-treated the abdominal pain with a variety of over-the-counter preparations such as antacids and H2 receptor antagonists. Difficulties in swallowing (dysphagia) can also result in abdominal discomfort.

V. Nausea and Vomiting Nausea and vomiting are commonly associated with GI problems, and the nurse assesses for onset, frequency, duration, patterns of occurrence, relationship to meals, and the quantity and character of the emesis. Nausea and vomiting are commonly associated with medication administration. Emesis may contain red blood indicative of recent bleeding. "Coffee-ground" emesis may indicate old bleeding in the stomach. The presence of bile produces a green color and has a bitter taste; brown vomitus may contain fecal matter.

VI. Fatigue and Weakness Persons with GI system problems often complain of fatigue or weakness. Inadequate nutrient intake, abnormal fluid and electrolyte status, and increased metabolic demands may all contribute to the problem. It is important for the nurse to carefully consider other problems that may be contributing to the symptoms, including cardiac, respiratory, renal, and other metabolic disorders. These complaints may be present in a wide variety of situations, but their careful assessment is essential for planning an overall approach to care. Resolution of these problems usually takes time. Fatigue and weakness may also contribute to weight loss, particularly when associated with persistent anorexia, nausea, vomiting, or abdominal pain.

VII. Elimination Patterns Patterns of bowel elimination vary significantly among healthy individuals, and these patterns are commonly altered by GI system disorders. The nurse assesses the individual's usual elimination pattern and explores any changes that have occurred. The use of laxatives, suppositories, or other products to support bowel elimination is carefully assessed.Changes in the normal pattern of bowel elimination may represent a physiologic alteration, a pathologic condition, or simply a change in normal diet and activity patterns. Constipation, defined as the presence of small, hard stools that are passed with difficulty at infrequent intervals, is a classic example. Constipation may be a temporary response to a change in diet or activity, or it may be a sign of bowel obstruction. Constipation may also result from the administration of opioids that slow peristalsis, whereas diarrhea can be the result of surgical interventions that remove significant bowel segments. Diarrhea and stools containing mucus, pus, and possibly undigested food may indicate enteritis or invasion by a parasite. Obstruction in the descending colon may produce small, ribbon-shaped stools, or no stool if the obstruction is complete.When fat absorption is abnormal, steatorrhea (bulky, foul-smelling, fatty stools) may occur. If biliary obstruction is present, the patient may give a history of clay-colored (grayish) stools. Bright red blood in the stool indicates lower GI bleeding. Blood from the upper GI tract is broken down by digestive secretions, and the stool appears black and sticky (tarry). Sometimes the presence of blood in the GI tract acts as a powerful cathartic and may produce abrupt, severe diarrhea. Blood in the stool (melena) may be a recent or a chronic symptom and may result from erosion of the mucosa, leading to perforation of the muscle wall or rupture of a blood vessel. All cases of melena and/or rectal bleeding should be immediately explored since both are symptoms associated with colorectal cancer.

PHYSICAL EXAMINATION Information gained from the physical examination helps the nurse determine the patient's baseline status and develop an appropriate plan of care.

I. MouthAssessment of the mouth provides data about the patient's ability to salivate, masticate, and swallow. The lips are observed for symmetry, color, moisture, swelling, cracks, or lesions. If asymmetry is noted, the ability to masticate and swallow is assessed. A tongue blade and penlight are needed to improve visualization, and gloves should be worn for all examinations of the mouth. In certain situations, a mask and eye shield may also be appropriate.The lips are normally reddish in color and are good indicators of pallor or cyanosis. Dryness may indicate dehydration, and cracks or fissures can occur with excessive dryness, exposure to cold, poorly fitting dentures, or a riboflavin deficiency. When cracks occur in the corners of the mouth they are referred to as angular stomatitis. Swelling of the lips is usually the result of an inflammatory response. Lesions on the lips may be benign or malignant. A commonly encountered benign lesion is herpes simplex (cold sore, fever blister), which is caused by a virus and can create enough discomfort to limit mastication.The enamel surface of the teeth should be white but will darken with surface stains (tea, coffee, tobacco). Commonly found abnormalities of the teeth include caries, loose or broken teeth, and absence of some or all teeth. The gums or gingivae are normally pink, attach to the teeth, and fill the interdental surfaces. Recession of the gum line is not uncommon in older individuals. If the person is partially or completely edentulous (without teeth), the gingivae are examined for areas of redness caused by improperly fitting dentures, partial plates, or implants. The person is then asked to insert the dentures so their correct fit and comfort for chewing can be assessed.

The buccal mucosa is light pink, although patchy pigmentation is seen in dark-skinned individuals. The mucosa is examined for moisture, white spots or patches, debris, areas of bleeding, or ulcers resulting from ill-fitting dentures or braces. Dryness and debris may indicate dehydration. White, curdy patches, which are removable with some effort, may be caused by candidiasis (thrush). White, nonremovable patches (leukoplakia); white plaques within red patches; or red, granular patches (erythroplakia) may be premalignant lesions and should be reported to the physician. A round or oval white ulcer surrounded by an area of redness is indicative of an aphthous ulcer (canker sore).While the tongue is depressed with a tongue blade and the person says "Ah," the soft palate is observed for symmetry and the effective functioning of cranial nerve X, the vagus, which is necessary for effective swallowing. The uvula, soft palate, tonsils, and posterior pharynx are observed for signs of in flammation. Tongue mobility and function are essential to mastication, taste, and swallowing. Normally there is no limitation to movement in any direction, but the tongue deviates toward the paralyzed side with paralysis of the twelfth cranial nerve (hypoglossal). A thin, white coating and presence of large papillae on the dorsum of the tongue are normal findings. A thick coating indicates poor oral hygiene; and a smooth, red surface suggests a nutritional deficiency. The ventral surface is examined for leukoplakia, ulceration, or nodules, any of which may indicate malignancy.Any distinctive odor of the breath is noted. A foul odor may occur after the ingestion of certain foods, with poor hygiene or oral infections, and with some metabolic dysfunctions such as diabetic ketoacidosis, liver disease, and bowel obstruction. Normally the mandible slides forward and down without difficulty, and a "cracking" sound is audible when the mouth is opened widely. The interior of the mouth is also carefully examined with a gloved finger to check for areas of tenderness, ulcers, and lumps.

II. Abdomen Examination of the abdomen determines the presence or absence of (1) tenderness, (2) organ enlargement, (3) masses, (4) spasm or rigidity of the abdominal muscles, and (5) fluid or air in the abdominal cavity. Physical examination of the abdomen is performed in the following order: inspection, auscultation, percussion, and palpation. Auscultation is performed before percussion and palpation, because the latter two may alter the frequency and intensity of bowel sounds.The surface of the abdomen can be divided anatomically into either four quadrants or nine regions. The patient is placed in a supine position and kept as relaxed as possible. Bending the patient's knees slightly, placing a small pillow under the head, and positioning the patient's arms flat on the bed can help the patient to relax the abdominal muscles and make palpation easier. Good lighting should be available.

II.I. Inspection Finding Interpretation

Scars or striae May be result of pregnancy, obesity, ascites, tumors, edema, surgical procedures, or healed burned areas

Engorged veins May be caused by obstruction of vena cava or portal vein and circulation from abdomen

Skin color variation

May be caused by jaundice (yellow), inflammation (red), or intraabdominal hemorrhage (blue)

Visible peristalsis May be caused by pyloric or intestinal obstruction; normally peristalsis not visible except for slow waves in thin persons

Visible pulsations Normally slight pulsation of aorta, visi ble in epigastric region Visible masses and altered contour

Observe for hernias, distention of ascites, and obesity; instructing patient to cough may bring out hernia "bulge" or elicit pain or discomfort in the abdomen; marked concavity may be caused by malnutrition

Spider angioma Appear on upper part of body and blanch with pressure; commonly result from liver disease

III. Auscultation

Finding Interpretation

Absence of bowel sounds in 5 minutes

Peritonitis, paralytic ileus, and hypokalemia

Repeated, high-pitched bowel sounds occurring at frequent intervals

Increased peristalsis caused by gastroenteritis, early pyloric obstruction, early intestinal obstruction, or diarrhea

Bruit Presence of abnormal sound caused by turbulence of blood flow through partially occluded or diseased aorta or renal artery

Hum and friction rub Heard over liver and splenic areas, indicating an increased venous blood flow, possibly related to peritoneal inflammation

IV. Percussion Percussion of the abdomen is used primarily to confirm the size of various organs and to determine the presence of excessive amounts of fluid or air. Normally, percussion over the abdomen is tympanic because of the presence of a small amount of swallowed air within the GI tract. A dull or flat percussion note is found over a solid structure. Dull sounds normally occur over the liver and spleen or a bladder filled with urine. Abnormal percussion findings occur because of the presence of ascites or abnormal masses. Ascites classically produces a shifting dullness, which is caused by fluid movement to dependent areas. Interpreting the sounds of abdominal percussion may be difficult in obese individuals.The four quadrants are percussed beginning with the thorax and moving downward systematically. The degree of tympany, from soft to pronounced, is recorded. Tympanic sounds should be heard beginning at the ninth interspace in the left upper quadrant of the abdomen.

V. Palpation Palpation is of value in determining the outlines of abdominal organs, the presence and characteristics of any abdominal masses, and the presence of direct tenderness, guarding, rebound tenderness, and muscular rigidity. In the presence of gallbladder disease, normal palpation of the liver elicits sharp pain and a positive inspiratory arrest (Murphy's sign). The acute onset of pain causes the patient to stop inspiration abruptly, midway through the breath.Abnormal findings from palpation may include (1) direct tenderness over an organ capsule, (2) rebound tenderness, (3) muscular rigidity, or (4) masses that may be felt if they are large enough or close enough to the surface. Distinction should be made between a distended abdomen that is firm to the touch and one that is soft to the touch.Light palpation is used to elicit tenderness and cutaneous hypersensitivity. The nurse uses the pads of the fingertips, with the fingers together, and presses gently, depressing the abdominal wall about 1 cm. All quadrants are palpated using smooth movements.Deep palpation is used to delineate organs and masses and should be performed only by properly trained persons because improper technique can result in injury. The nurse again uses the palmar surface of the fingers but presses more deeply using a single- or two-handed technique. Known tender or painful areas should be assessed last. Rebound tenderness is tested by pressing slowly but firmly over the painful site. The fingers are then quickly withdrawn. Acute pain on withdrawal reflects peritoneal inflammation (positive Blumberg's sign). This maneuver can be extremely painful and should never be performed unnecessarily.

VI. Rectum The normal perineal and perianal skin resembles the skin on the rest of the body with no breaks in integrity. Abnormal findings may include pruritus ani, coccygeal or pilonidal sinus tract openings, fistulas, fissures, external hemorrhoids, or rectal prolapse. Internal hemorrhoids may appear when the patient bears down

DIAGNOSTIC TESTS Laboratory testsStool Examination Radiologic Tests (Rx, Ultrasound, Computer Tomography, Radionuclide Imaging, Cholecystography, Cholangiography)

Special TestsEsophageal Function Tests (Manometry, pH Monitoring, Esophageal Clearance Test, Acid Perfusion Test (Bernstein Test))Tests of Gastric Function (Gastric Analysis (Basal Gastric Secretion and Gastric Acid Stimulation Tests), Tubeless Gastric Analysis (Diagnex Blue Test), Schilling Test (vitamin B12 absorption), Urea Breath Test)Biopsy (Upper Gastrointestinal Biopsy, Intestinal Biopsy Intestinal Biopsy)Endoscopy (Esophagogastroduodenoscopy, Endoscopic Retrograde Cholangiopancreatography, Colonoscopy)