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. - Constant pain in your upper belly that radiates to your back. This is a
Began 24 hours ago and is worsening. symptom of pancreatitis.
Nauseous -Nausea from alcohol intake which increases the production of stomach acids and
Puked green liquid 5x. delays the stomach from emptying. Also signs of pancreatitis.
2 loose stool dark brown/black -Green/yellow vomit could indicate bile produced by the gallbladder.
Crying about sons death -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 Ibuprofen 600 mg NSAID nonsteroidal IBUPROFEN- reduces pain and inflammation in the
PO three times anti-inflammatory body.
Low back pain
daily PRN drugs
Pancreatitis Citalopram 40 SSRI serotonin- Citalopram- used for depression
(no current meds) mg PO daily reuptake inhibitors
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
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. - Constant pain in your upper belly that radiates to your back. This is a
Began 24 hours ago and is worsening. symptom of pancreatitis.
Nauseous -Nausea from alcohol intake which increases the production of stomach acids and
Puked green liquid 5x. delays the stomach from emptying. Also signs of pancreatitis.
2 loose stool dark brown/black -Green/yellow vomit could indicate bile produced by the gallbladder.
Crying about sons death -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 Ibuprofen 600 mg NSAID nonsteroidal IBUPROFEN- reduces pain and inflammation in the
PO three times anti-inflammatory body.
Low back pain
daily PRN drugs
Pancreatitis Citalopram 40 SSRI serotonin- Citalopram- used for depression
(no current meds) mg PO daily reuptake inhibitors
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
