Subjective GI Assessment
You ask a patient to describe their abdominal discomfort, including when it began, what provokes or relieves it, what it feels like, where it is located, if it travels to another part of the body and where, perceived intensity on a scale of 1 - 10, and how long it has lasted. These details are part of this subjective assessment.
What is pain assessment?
The objective GI assessment contains these four actions, which are also part of the routine head-to-toe assessments performed on patients.
What is inspection, auscultation, percussion and palpation?
A patient reports upper abdominal burning and gnawing discomfort that occurs shortly after meals and worsens with spicy foods or stress. On assessment, mild tenderness is noted in the upper central abdomen. These findings are characteristic of inflammation involving this organ.
What is the stomach?
A patient reports vomiting that appears dark and grainy, resembling coffee grounds. This finding is a red flag for this potentially serious GI condition.
What is upper gastrointestinal bleeding?
A 42-year-old office worker reports eating a balanced, high-fiber diet with adequate hydration, denies nausea or vomiting, and has regular morning bowel movements. Upon assessment of the patient's abdomen you note that the abdomen is flat, non-tender, with active bowel sounds in all abdominal quadrants.
What are normal GI assessment findings?
When asking about weight loss or gain, food intolerances, and difficulty chewing or swallowing, you are assessing this aspect of the GI subjective assessment.
What is appetite and dietary changes?
This part of the objective GI assessment is always performed first and involves observing the abdominal shape, skin abnormalities, visible pulsations, and any openings or incision sites.
What is inspection?
A patient reports cramping, bloating, and discomfort in the left lower quadrant, along with alternating episodes of constipation and diarrhea. These recurring symptoms, often worsened by stress or certain foods, primarily affect this abdominal organ.
What is the large intestine/colon (specifically the descending and sigmoid colon)?
During abdominal auscultation, no bowel sounds are heard for 5 minutes (in any of the abdominal quadrants), and the abdomen appears distended. These findings suggest this emergency condition involving a lack of intestinal movement.
What is bowel obstruction?
A 72-year-old patient reports no bowel movement in five days, decreased appetite, and mild abdominal discomfort. The abdomen appears distended with hypoactive bowel sounds, and the patient recently began taking iron supplements for anemia. These findings are most consistent with this common gastrointestinal condition.
What is constipation?
A patient reports passing fewer stools than usual. When they do pass a stool it is hard and dark/tarry. Upon review of the patient's reported meals, you notice that they could incorporate more fruit and vegetables into their diet. The patient also denies use of any laxatives. These findings relate to this subjective component of the GI history.
What are bowel patterns?
Using the diaphragm of your stethoscope, you listen in all four quadrants of the patient's abdomen, starting in the right lower quadrant and moving in a clockwise direction. You also expect to hear 5–30 bowel sounds per minute in a normally functioning GI system.
What is auscultation?
A patient reports sharp pain in the right lower quadrant, accompanied by nausea and rebound tenderness at McBurney’s point. These findings are classic indicators of inflammation in this part of the gastrointestinal tract.
What is the appendix?
During your abdominal assessment, the patient’s abdomen feels rigid and board-like to the touch. This finding may indicate this life-threatening complication caused by inflammation or perforation of abdominal organs.
What is peritonitis?
A 54-year-old patient reports a burning sensation behind the breastbone that worsens when lying flat or after large meals. The discomfort improves with antacids. These symptoms result from dysfunction of this muscular valve between the esophagus and stomach.
What is gastroesophageal reflux disease (GERD)?
During a gastrointestinal assessment, the nurse asks the patient about sensations of queasiness or an urge to expel stomach contents, as well as the frequency, appearance, and presence of blood or bile in any expelled material. This line of questioning focuses on identifying this group of related digestive symptoms.
What is nausea, vomiting, or reflux?
Using the bell of your stethoscope, you listen to the patient's abdomen, and hear an abnormal "whooshing" sound in both the right and left upper quadrants near the midline. This is the medical term for the abnormal "whooshing" you auscultated.
What are bruits?
A patient reports pain in the left upper quadrant that radiates to the back, along with nausea and vomiting following alcohol intake. These findings are characteristic of inflammation in this abdominal organ.
What is the pancreas?
Your patient presents with yellowing of the skin and sclera (white outer layer of the eyes), dark-colored urine, and pale stools. These findings indicate this underlying systemic issue related to impaired bilirubin metabolism.
What is liver dysfunction or jaundice?
A 68-year-old patient reports poor appetite, unintentional weight loss, and fatigue. On assessment, you note pale conjunctiva (inner lining of the eyelid) and dark, tarry stools. These findings are most concerning for this underlying condition related to chronic blood loss.
What is gastrointestinal bleeding leading to anemia?
During your review of the patient's chart you notice recent appendectomy under surgical interventions. Upon review of the patient's bloodwork you also note that ALT, AST, ALP, and GGT are higher than normal. The patient also mentions a history of intermittent urinary urgency. These findings belong to this category of the subjective GI assessment.
What is other relevant GI history (GI disorders, GI surgeries, and urinary symptoms)?
During palpation of the patient's back, they report tenderness when you gently tap over the costovertebral angle, where the 12th ribs articulate with the vertebrae of the spine. This finding may indicate inflammation or infection of this organ.
What is/are the kidney(s)?
A patient reports discomfort in the right upper quadrant after eating a fatty meal, with pain radiating to the right shoulder. On assessment, the nurse notes mild tenderness beneath the right costal margin and possible guarding. These findings are characteristic of inflammation of this abdominal organ.
What is the gallbladder?
A patient reports unexplained weight loss, persistent diarrhea, and the presence of blood in the stool. Taken together, these findings raise concern for this serious underlying diagnosis affecting the gastrointestinal tract.
What is gastrointestinal malignancy (such as colorectal cancer)?
A 60-year-old patient reports intermittent cramping pain and bloating in the lower abdomen, accompanied by low-grade fever and changes in bowel habits. The pain is localized to the left lower quadrant and worsens after meals. On assessment, there is mild tenderness and guarding in the affected area, but no rebound tenderness. These findings are most consistent with this inflammatory condition involving small pouches along the colon wall.
What is diverticulitis?