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 Could be due to alcohol abuse, acute abdominal pain
progressively worse is a red flag
Nauseated and puked 5x in last Bile reflux
hour Two loose stool dark brown Bleeding in upper digestive tract or
or black ETOH use/abuse ulcer Can lead to pancreatitis
Crying - 1 year anniversary of Reason why pt is drinking a lot. Nurse has to
son’s death (drinking 1 liter of provide therapeutic and holistic care.
vodka daily)
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 Nonsteroidal Used to treat pain, fever,
Low back pain PO three times anti- and inflammation
Pancreatitis daily PRN inflammatory
Citalopram 40
(no current meds) drugs (NSAIDS) Boosts the level of the serotonin in
mg PO daily
ETOH abuse Selective the brain to improve the patient’s
(no current meds) serotonin mood and decrease the feeling of
reputable anxiety
inhibitors
SSRIs
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:
Copyright © 2019 Keith Rischer, d/b/a KeithRN. All Rights
reserved.
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 Could be due to alcohol abuse, acute abdominal pain
progressively worse is a red flag
Nauseated and puked 5x in last Bile reflux
hour Two loose stool dark brown Bleeding in upper digestive tract or
or black ETOH use/abuse ulcer Can lead to pancreatitis
Crying - 1 year anniversary of Reason why pt is drinking a lot. Nurse has to
son’s death (drinking 1 liter of provide therapeutic and holistic care.
vodka daily)
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 Nonsteroidal Used to treat pain, fever,
Low back pain PO three times anti- and inflammation
Pancreatitis daily PRN inflammatory
Citalopram 40
(no current meds) drugs (NSAIDS) Boosts the level of the serotonin in
mg PO daily
ETOH abuse Selective the brain to improve the patient’s
(no current meds) serotonin mood and decrease the feeling of
reputable anxiety
inhibitors
SSRIs
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:
Copyright © 2019 Keith Rischer, d/b/a KeithRN. All Rights
reserved.
