Subjective Findings
You ask a patient to describe their abdominal pain, including its onset, location, duration, and character. These details are part of assessing this aspect of the GI system.
What is pain assessment?
This is part of your Head-to-Toe assessment performed on patients. The GI assessment contains four objective assessments
What is inspection, auscultation, percussion and palpation
A patient reports vomiting that looks like coffee grounds. This is a red flag for this potentially serious condition
What is upper gastrointestinal bleeding?
A patient reports pain in the right upper quadrant after eating a fatty meal. The pain radiates to the right shoulder.
What is gallblader?
A nurse is assessing a client with abdominal pain. This is a framework that is used to assess pain.
What is OPQRST?
(Onset, Provoke, Quality, Radiate, Severity, Timing)
When asking about changes in appetite, food intolerances, and difficulty swallowing, you are assessing this area of the GI subjective assessment.
What is appetite and dietary changes?
This part of the GI assessment is always performed first and involves observing the abdominal contour, skin, visible pulsations, and any stoma or incision sites
What is inspection?
During your assessment, the patient’s abdomen feels rigid and board-like. This could indicate this life-threatening complication.
What is peritonitis?
A patient complains of sharp pain in the right lower quadrant, accompanied by nausea and rebound tenderness at McBurney’s point.
What is the appendix?
A 42-year-old office worker reports eating well, no nausea or vomiting, and regular bowel movements every morning. Abdomen is flat, non-tender, with active bowel sounds in all quadrants
What is a normal GI finding?
A patient reports having fewer bowel movements than usual, and their stool is hard and difficult to pass. These findings relate to this component of the GI history.
What are bowel patterns?
Using the diaphragm of your stethoscope, you listen in all four quadrants starting in the right lower quadrant, expecting 5–30 bowel sounds per minute
What is auscultation?
You auscultate the abdomen and hear no bowel sounds for 5 minutes. The abdomen appears distended. These findings suggest this emergency condition.
What is bowel obstruction?
A patient reports cramping and bloating with discomfort across the left lower quadrant, along with constipation alternating with diarrhea.
What are the descending and sigmoid colon?
A 68-year-old patient reports poor appetite, unintentional weight loss, and fatigue. You note pale conjunctiva and dark stools during assessment.
What is a possible upper GI bleed?
You ask about the frequency and characteristics of vomiting, such as whether it contains blood or bile. This line of questioning focuses on identifying the presence of these symptoms.
What are nausea, vomiting, or reflux?
This finding occurs when there are fewer than 5 bowel sounds per minute and may be seen post-operatively or with bowel obstruction.
What is hypoactive bowel sounds?
Your patient presents with yellowing of the skin and sclera, dark urine, and pale stools. These findings indicate this underlying systemic issue.
What is liver dysfunction or jaundice?
A patient reports pain in the left upper quadrant that radiates to the back, along with nausea and vomiting after alcohol intake.
What is the pancreas?
A 72-year-old patient reports no bowel movement in five days, decreased appetite, and mild abdominal discomfort. On inspection, the abdomen appears distended. Bowel sounds are hypoactive, and the patient says they recently started taking iron supplements for anemia.
What is constipation likely related to medication use and decreased motility?
During your assessment, the patient mentions a history of appendectomy and intermittent urinary urgency. These belong under this final section of the subjective GI interview.
What is other relevant history (GI disorders, surgeries, and urinary symptoms)?
During palpation, the patient reports sharp pain when you gently tap over the costovertebral angle. This finding may indicate inflammation or infection of this organ.
What is the kidney?
A patient reports unexplained weight loss, persistent diarrhea, and blood in the stool. Taken together, these subjective and objective findings raise concern for this serious underlying diagnosis.
What is gastrointestinal malignancy (such as colorectal cancer)?
A patient presents with jaundice, dark urine, and clay-colored stool. These findings suggest a problem in the flow of bile through this organ system.
What is the hepatobiliary system (liver, gallbladder, and bile ducts)?
A 60-year-old patient reports clay-colored stools, itching skin, and dark urine. On inspection, the sclera and skin appear yellow.
What is obstructive jaundice due to impaired bile flow?