12 Focused Assessment- Gastrointestinal and Genitourinary

Learning Objectives

At the end of this chapter, the learner will:

  1. Provide safety and privacy during gastrointestinal and genitourinary assessments.
  2. Identify the location of the organs contained in the abdominal cavity.
  3. Obtain health history relevant to the gastrointestinal and genitourinary assessments.
  4. Describe two methods (4 quadrants and 9 regions) of anatomic mapping used to describe findings related to the abdominal assessment.
  5. Perform gastrointestinal and genitourinary assessments using the correct exam order and techniques.
  6. Document findings of the gastrointestinal and genitourinary systems using correct medical terminology.

I. Overview of the gastrointestinal (GI) and Genitourinary (GU) Systems:

The gastrointestinal (GI) system is responsible for the ingestion of food, the absorption of nutrients, and eliminating waste as stool.  The genitourinary (GU) system, also called the renal or urinary system is responsible for electrolytes and pH balance, blood volume and pressure,  and eliminates waste as urine.

II. Anatomy and Physiology

Please use the following videos and other learning tools to review the Anatomy and Physiology of the Gastrointestinal system and Genitourinary systems.  The first picture is of all organs within the gastrointestinal system. Use this picture to identify organs within each abdominal quadrant or within each region when utilizing the four quadrants and/or the 9 region methods to systematically exam the abdomen and/or document the findings.

Gastrointestinal System

The four quadrants and the nine regions method of identifying organs in the abdomen

There are (a) nine abdominal regions and (b) four abdominal quadrants in the peritoneal cavity 

The video below demonstrates peristalsis in the large intestines.

The GI tract has three priority functions: digestion of food,  absorption of nutrients, and elimination of waste. Digestion involves breaking down into its smallest parts so nutrients can be absorbed. There are two types of digestion. The first is mechanical and this process is completed in the mouth and stomach by chewing food into smaller pieces. Chemical digestion occurs later and chemicals are used to break down food molecules even more to even smaller molecules for easier absorption. Absorption occurs when nutrients pass through to the bloodstream or lymph system and is circulated throughout the body. Anything not digested and absorbed is moved to the anus for elimination.

The small intestine is the area in which most digestion occurs.  There is the completion of proteins and carbohydrates digestion and lipids are solely digested in the small intestine. Most of the water from food is reabsorbed here.   There are three sections called the duodenum, jejunum, and Ileum.

Please click on this link for further information about the small intestine: https://openstax.org/books/anatomy-and-physiology/pages/23-5-the-small-and-large-intestines

The large intestine also called the Colon processes chyme, reabsorbs water, electrolytes, and vitamins from waste prior to it becoming feces. It also produces vitamins B and K . There are four parts to the large intestine and these include the cecum, the ascending colon, transverse colon, descending colon, and the sigmoid colon.

Please click on this link for further information about the large intestine: https://www.ncbi.nlm.nih.gov/books/NBK507857/

The Genitourinary System:

The organs of the Genitourinary system
The organs of the Genitourinary system

The GU system is made up of the kidneys, ureters, urinary bladder, and urethra. This system is responsible for:

  • regulating pH
  • synthesizing vitamin D
  • producing erythropoietin
  • cleaning the blood of waste
  • reabsorbing sodium, water, glucose, amino acids, and vitamins
  • produces renin for the Aldosterone-Renin-Angiotensin system
  • producing urine to rid the body of waste. The GU system includes the kidneys, ureters, urinary bladder, and urethra.

Please click on this link for further information about the GU system: https://courses.lumenlearning.com/nemcc-ap/chapter/gross-anatomy-of-the-kidney/

Knowledge Check

III. Medical Terminology

Ascites accumulation of fluid in the peritoneal cavity
Anuria no urine; 24-hour urine output is less than 100 mL
Azotemia high levels of nitrogen-containing compounds (body waste) in the blood
Blood urea nitrogen (BUN) a blood test to check the amount of urea nitrogen
Creatinine a waste generated from muscle metabolism
Diuresis increase in urine excretion
Frequency increase number of urinations
Gastroesophageal Reflux Disease (GERD) Stomach acid flows up from the stomach into the esophagus causing heartburn
Hematemesis vomiting blood
Hesitancy Inability to start or maintain a urine stream
Hematuria Blood in urine
Hiatal Hernia the protrusion of the stomach through the esophageal opening in the diaphragm
Hypervolemia too much fluid in the blood
Hypovolemia a decreased volume of circulating blood in the body.
Incontinence loss of bladder control leading to involuntary urination
Melena dark tarry sticky feces containing blood
Oliguria inadequate production or secretion of urine; 24-hour urine output less than 400 mL
Peristalsis the involuntary constriction and relaxation of the muscles of the intestine
Peritoneum the serous membrane lining the cavity of the abdomen and covering the abdominal organs
Polyuria the excessive output of urine (diuresis)
Rebound Tenderness pain felt when pressure as to the abdomen is suddenly removed
Urea a nitrogen-containing substance normally cleared from the blood by the kidney into the urine
Urinary Retention inability to empty the bladder completely
Urinary Stasis Urine flow has been impaired and is used interchangeably with urinary retention.
Urinary Tract Infection (UTI) an infection in the urinary system

Knowledge Check

Assessment of the gastrointestinal system includes obtaining relevant subjective and objective data and is focused on the mouth and abdomen. The genitourinary system assessment also needs subjective and objective data and focuses on the examination of the body’s ability to get rid of urine, the genitalia, and the urine itself.

Pain is the most common complaint related to abdominal problems and can be attributed to multiple underlying etiologies. Because of the potential variability of contributing factors, a careful and thorough assessment of this chief complaint should occur.

Nausea, vomiting, diarrhea, and constipation are common issues experienced by hospitalized patients due to adverse effects of medications or medical procedures. It is important to ask a hospitalized patient daily about the date of their last bowel movement and flatus so that a bowel management program can be initiated if necessary. If a patient is experiencing diarrhea, it is important to assess and monitor for signs of dehydration or electrolyte imbalances.  Dehydration can be indicated by dry skin, dry mucous membranes, or sunken eyes. These symptoms may require contacting the health care provider for further treatment.

Additional specialized assessments of GI system function can include examination of the oropharynx and esophagus. For example, patients who have experienced a cerebrovascular accident (CVA), also called a “stroke,” may experience difficulty swallowing (dysphagia). The nurse is often the first to notice these difficulties when swallowing pills, liquid, or food and can advocate for treatment to prevent complications, such as unintended weight loss or aspiration pneumonia.[4]

The nursing assessment of the genitourinary system generally focuses on bladder function. Ask about urinary symptoms, including, urinary frequency, or urinary urgency. Dysuria is any discomfort associated with urination and often signifies a urinary tract infection. Patients with dysuria commonly experience burning, stinging, or itching sensations. In elderly patients, changes in mental status may be the presenting symptom of a urinary tract infection. In women with dysuria, asking whether the discomfort is internal or external is important because vaginal inflammation can also cause dysuria as the urine passes by the inflamed labia.

Abnormally frequent urination (e.g., every hour or two) is termed urinary frequency. In older adults, urinary frequency often occurs at night and is termed nocturia. The frequency of normal urination varies considerably from individual to individual depending on personality traits, bladder capacity, or drinking habits. It can also be a symptom of a urinary tract infection, pregnancy in females, or prostate enlargement in males.

Urinary urgency is an abrupt, strong, and often overwhelming need to urinate. Urgency often causes, a leakage of urine. When patients experience urinary urgency, the desire to urinate may be constant with only a few milliliters of urine eliminated with each voiding.[5

IV. Step by Step Assessment

  • Perform hand hygiene.
  • Check room for contact precautions.
  • Introduce yourself to the patient.
  • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
  • Explain the process to the patient.
  • Assemble equipment prior to starting the exam.
  • Be organized and systematic in your assessment.
  • Use appropriate listening and questioning skills.
  • Listen and attend to patient cues.
  • Ensure patient’s privacy and dignity.
  • Apply principles of asepsis and safety.
  • Check vital signs.
Steps
 Additional Information
1. Conduct a focused interview related to the Gastrointestinal system. Ask relevant questions to obtain subjective data relevant to:

  • is there any history of gastrointestinal disease in the family? (Eshogeal, stomach, colon or rectal cancer)
  • is there any difficulty chewing and/or swallowing? ( overlap from the HEENT system)
  • is there any problem with teeth or does the patient wear dentures? (overlap from the HEENT system)
  • what type of diet does the patient follow? Has there been a recent change in food tolerance?
  • What medication is the patient taking including laxatives or enemas?
  • has there been an unexplained weight loss or weight gain in the last six weeks?
  • is heartburn a problem and if it is when and how often is it experienced?
  • is the patient experiencing more flatus than normal?
  • is the patient experiencing nausea, vomiting, diarrhea, or constipation?
  • Are there any bloody stools including hematochezia; melena; bloating (abdominal distention), or hematemesis?
  • When was the last bowel movement and what did it look like?
  • is there any pain or tenderness to the abdomen and if so point to the area? Utilize OLD CART to obtain symptoms.
2. Inspect:

  • the mouth, teeth, and the ability to swallow
  • the skin and oral mucosa for signs of dehydration
  • the sclera, nails bed, and palm/soles for signs of jaundice and anemia
  • the abdomen for color, shape, contour, symmetry, scars, striae, distention, or any visible masses.
  • the umbilicus for shape, positioning, herniation, or discharge.
  • Observe for any abdominal movements associated with respiration, or any pulsations or peristaltic waves
  • Inspect the suprapubic area (from umbilicus to pelvis) for distention.
  • While observing the abdominal wall, ask the patient to cough. No bulging from anywhere on the abdominal wall should be noted as bulging could be a sign of a hernia.
  • Abdominal distension may indicate ascites associated with conditions such as heart failure, cirrhosis, and pancreatitis.
  • Abdominal distension may indicate ascites associated with conditions such as heart failure, cirrhosis, and pancreatitis.
    Ascites
    Ascites

    Markedly visible peristalsis with abdominal distension may indicate intestinal obstruction.

     

    Striae
    Striae
    Urinary Retention
    Bladder Distention

     

    Umbilical Hernia
    Umbilical Hernia
3. Auscultate the abdomen in all four quadrants

  • Auscultation is performed prior to palpation to prevent altering the regularity of bowel sounds.
  • Abdominal examination (text)
  • When bowel sounds are not present, a minimum of 5 minutes should be auscultated before determining the bowel sounds are absent.
  • Please focus on the auscultation portion of the video.
  • For bruits at the Aortic, Renal, and Illiac arteries.  Most of the time nurses do not auscultate for abdominal bruits at main blood vessels.
  • Nurses do not assess the Hepatic and Splenic arteries. 
4. Palpate the abdomen

  • Begins farthest away from pain
  • press abdomen lightly (1-2 cm) in all four quadrants.
  • Assess for rigidity, discomfort, or masses.
  • Gently palpate the suprapubic area. It should be felt soft, non-tender, and non-distended. A distended bladder is palpated as suprapubic fullness which indicates urinary retention. The patient may experience pain in the bladder, abdomen, and or lower back.
  • Documentation of normal findings: Abdomen is soft, non-distended, non-tender with positive bowel sounds to all four quadrants.
 In the MC nursing program, percussion is considered an advanced practice skill and is not an expectation for students. Therefore, the next step of the abdominal assessment will be palpation.

Nurses complete light palpation only. All four quadrants need to be palpated.

 
5. Report and document assessment findings and related health problems according to agency policy. Accurate and timely documentation and reporting promote patient safety.

 

Steps
 Additional Information
1. Conduct a focused interview related to the Genitourinary system. Ask relevant questions to obtain subjective data relevant to:

  • is there a history of diabetes, heart disease, renal disease, prostate disease, urinary tract infections, kidney stones, pelvic inflammatory disease, incontinence, nocturia, sexually transmitted infections, or trauma to the genitourinary system required catheterization?
  • is there any difficulty urinating?
  • how often does the patient urinate and approximately how much?
  • what is the color of the urine? Is there any Hemituria,
  • has the odor or appearance of the urine changed recently?
  • is the patient experiencing itching, burning, irritation, hesitancy, frequency, urgency, or incomplete emptying with urination?
  • has the patient noticed a change in energy and eating habits?

 
 Inspect

  • The face, upper and lower extremities for edema.
  • Inspect the suprapubic area and abdomen for distention indicating bladder distention. Please click on the link below and scroll down to inspect a patient with a distended bladder:                                               A patient with visible bladder distention

 

 

  • Inspect the color, odor, and volume of urine and send a sample for tests as ordered.
  • Inspect weight and assess for unexpected weight gain or weight loss. Unexpected weight loss can occur with renal disease from a lack of appetite and fatigue. Unexpected weight gain can occur with fluid retention as kidneys cannot get rid of waste and fluid.

 
  • Inspect the neck, scapula, chest, arms, and femoral areas for Hemodialysis access sites or abdomen for the peritoneal access site.
  • If the patient has a Foley catheter, inspect the bag for urine amount, color, and clarity. Inspect skin at the insertion site (meatus)  for redness/breakdown.
  • Closed Urinary Drainage catheter systemFile:Closed Urinary Drainage.png

A sample of narrative documentation

Sample of normal findings:

The patient denies any abdominal pain or change to bowel habits has a soft formed brown stool once a day. Denies any loss of appetite or change in weight. Denies any difficulty chewing or swallowing or any family history of abdominal cancers. The abdomen is the same color as the rest of the body with sparse hair distribution close to the perineum. The abdomen is rounded, symmetrical with straie around the waist. The umbilicus is midline and no odor or discharge noted. The abdomen is soft, non-distended, non-tender with positive bowel sounds to all four quadrants and no guarding noted during the assessment.

The patient denies any change to the urinary pattern and urinates 4-8 times a day, denies frequency, hesitancy, dysuria, hematuria, urgency, or incontinence. Denies any flank pain or change n appetite or energy. Abdomen flat and symmetrical, midline umbilicus, no scars, skin color consistent with the rest of the body. No distention to the suprapubic area and no edema to face, hand, or lower extremities noted.

VI. Related Laboratory and Diagnostic Procedures/Findings

Abdominal pain is the most common chief complaint related to abdominal assessment. This pain can be associated with the following: stomach/ intestine (digestion) problems, liver/gall bladder issues, pancreas problems, appendicitis, urinary tract problems, and or problems from the reproductive system. Therefore, in addition to information gathered from health history and physical assessment, some laboratory tests and diagnostic exams can assist in diagnosing the cause of the pain.

A complete blood count (CBC), is a blood test that can help determine if an infection is present in the body, like UTI (urinary tract infection) or peritonitis (infection of peritoneum).

Urinalysis is a urine test to determine if blood or infection is present in the urinary tract and may be ordered if the patient presents with pain to the abdomen, pelvis, back, or flank areas to check for a Urinary Tract Infection (UTI)

Liver Function Test (LFT), is a blood test to check the levels of liver enzymes. When liver enzymes are elevated the liver has been damaged and liver function may beimpaired.

Amylase and Lipase are blood tests to check the enzyme levels produced by the pancreas. Patients with pancreatitis will have elevated levels of these two enzymes.

Occult Stool/Hemoccult Test is a stool test. It checks the blood in stool that cannot be seen with the bare eye. Positive results indicate a problem (may be bleeding) in the gastrointestinal (GI) tract.

An X-ray of the abdomen (KUB) examines the kidneys, ureters, bladder, intestines, and the bones of the pelvis and spine. The following are seen on this type of XRAY:  kidney stone, gas in the GI tract, or constipation.

Ultrasound uses sound waves to create images. It is often used to diagnose problems with the gallbladder or the kidneys

Computed tomography (CT) scan is used to create more detailed images of the body.

Magnetic resonance imaging (MRI) uses magnetic fields to produce images of the body. However, it cannot be performed in patients who have metal in their bodies.

Esophagogastroduodenoscopy (EGD) uses an endoscope with a camera is inserted and progressed through the patient’s mouth, to the esophagus, to the stomach, and finally to the duodenum. This test is used to directly inspect the GI tract (up to the duodenum). This test will help diagnose acid reflux, ulcers, or mass (cancer).

Colonoscopy, like EGD, is a test to examine the inside of the colon with an endoscope. This test will help to diagnose cancer, diverticulitis (infection of small, bulging pouches in the digestive tract), and colitis.

A more detailed overview of about the GI and GU assessment please click on this link: https://wtcs.pressbooks.pub/nursingskills/chapter/12-3-gastrointestinal-and-genitourinary-assessment/

VII. Learning Exercises

 

VIII. Attributions and References

Narayan, R.  https://www.khanacademy.org/science/high-school-biology/hs-human-body-systems/hs-the-digestive-and-excretory-systems/v/meet-the-gastrointestinal-tract

Narayan, R. https://www.khanacademy.org/science/high-school-biology/hs-human-body-systems/hs-the-digestive-and-excretory-systems/v/how-do-our-kidneys-work

Human Physiology/The Urinary System. Provided by: Wikibooks. Located at: http://en.wikibooks.org/wiki/Human_Physiology/The_Urinary_System%23Introduction. License: CC BY-SA: Attribution-ShareAlike

Nursing Skills by Open Resources for Nursing (Open RN)  12.3 Gastrointestinal and Genitourinary Assessment by Wisconsin Technical College System Retrieved at 18:19 July 23, 2021 wtcs.pressbooks.pub/nursingskills/chapter/12-3-gastrintestinal-and-genitourinary-assessment/#footnote-385-1  is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted

Clinical Procedures for Safer Patient Care by Thompson Rivers University 2.10 Head-to-toe Assessment: Genitourinary Assessment located at: https://pressbooks.bccampus.ca/clinicalproceduresforsaferpatientcaretrubscn/chapter/2-9-head-to-toe-assessment-abdominal-gastrointestinal-assessment/ retrieved 19:39 at July 23, 2021is licensed under a Creative Commons Attribution 4.0 International License,

Overview of the Urinary System by Lumen Boundless Anatomy and Physiology Retrieved 18:30 at July 23, 2021, https://courses.lumenlearning.com/boundless-ap/chapter/overview-of-the-urinary-system/Provided by: Boundless.com. License: CC BY-SA: Attribution-ShareAlike

Introduction to the Digestive System by biology LibreTexts retrieved ar 20:00  July 23,2021 3 D Medical Animation-Peristalsis in Large Intestine https://youtu.be/Ujr0UAbyPS4

File: There are (a) nine abdominal regions and (b) four abdominal quadrants in the peritoneal cavity (2013, June 3). Wikimedia Commons, the free media repository. Retrieved 20:12, July 23, 2021, from https://commons.wikimedia.org/wiki/File:Abdominal_Quadrant_Regions.jpg

Anatomy & Physiology by Oregon State University 23.1 Overview of the digestive SystemAnotomy & Physiology provided by open Oregon state education retrieved at 21:30 July 23,2021 https://open.oregonstate.education/aandp/chapter/23-1-overview-of-the-digestive-system/

Step by Step Checklist adapted from https://opentextbc.ca/clinicalskills/chapter/2-5-focussed-respiratory-assessment/ by authors Glynda Rees Doyle and Jodie Anita McCutcheon

WikiDoc editors: Gibson, C. M. & Zorkun, C. (2015). Decreased bowel sounds. Retrieved 17:36, March 25, 2021. from https://www.wikidoc.org/index.php/Decreased_bowel_sounds#cite_ref-1

Wikipedia contributors. (2019, April 8). Abdominal examination. In Wikipedia, The Free Encyclopedia. Retrieved 01:19, August 30, 2019, from https://en.wikipedia.org/w/index.php?title=Abdominal_examination&oldid=891511595

File: Abdominal Quadrant Regions.jpg. (2018, February 11). Wikimedia Commons, the free media repository. Retrieved 02:37, August 30, 2019 from https://commons.wikimedia.org/w/index.php?title=File:Abdominal_Quadrant_Regions.jpg&oldid=286411593.
Auscultating the abdomen. Inspection, auscultation, and percussion by Medmastery December 14, 2020. Retrieved July 23, 2021 from https://www.youtube.com/watch?v=6xfvMnV08FM
Gastrointestinal-Palpation of the Abdomen by Top Hats Tutorials June 7h 2020. Retrieved 02:25 July 24, 2021 from https://youtu.be/0HFOaH11JmI
Wikipedia contributors. (2019, August 2). Colonoscopy. In Wikipedia, The Free Encyclopedia. Retrieved 22:49, September 10, 2019, from https://en.wikipedia.org/w/index.php?title=Colonoscopy&oldid=908979807
File: Belly Strech Marks.jpg. (2018, December 6). Wikimedia Commons, the free media repository. Retrieved 03:12, September 11, 2019 from https://commons.wikimedia.org/w/index.php?title=File:Belly_Strech_Marks.jpg&oldid=330499726.
File: Closed Urinary Drainage.png (2016, April 8) Wikimedia Commons, the free media repository. Retrieved 03:52, July 24, 2021 https://commons.wikimedia.org/wiki/File:Closed_Urinary_Drainage.png
Teach Me Surgery Acute Urinary Retention management: Retrieved 03:53, July 24, 2021 https://teachmesurgery.com/urology/presentations/acute-urinary-retention/
Azzouz LL, Sharma S. Physiology, Large Intestine. [Updated 2020 Jul 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK507857/
OpenStax, Anatomy and Physiology 23.5 The Small and Large Intestine  Retrieved  06:59 July 29, 2021 https://openstax.org/books/anatomy-and-physiology/pages/23-5-the-small-and-large-intestines
Wakim, S., & Grewal, M. (2021, June 10). Introduction to the Digestive System. Retrieved 0700 July 29, 2021, from https://bio.libretexts.org/@go/page/16831
Lumen Anatomy and Physiology Chapter 14: The Urinary System and the reproductive system. Retrieved 0700 July 29, 2021, https://courses.lumenlearning.com/nemcc-ap/chapter/gross-anatomy-of-the-kidney/

Wisconsin Technical College System 12.3 Gastrointestinal and Genitourinary Assessment one resources for Nursing (open RN) Retrieved 0845 July 29 2021 https://wtcs.pressbooks.pub/nursingskills/chapter/12-3-gastrointestinal-and-genitourinary-assessment/

Medical Terminology references:
Wikipedia The Free Encyclopedia (2021, July 6) Creatinine.Retrieved 23:00 July 23, 2021, from https://en.wikipedia.org/wiki/Creatinine
Wikimedia Commons Gastroesophageal reflux disease (GERD) Retrieved 23:11, July 23, 2021, https://commons.wikimedia.org/wiki/File:GERD.png
Wikipedia The Free Encyclopedia (2021, July 8) Creatinine.Retrieved 23:00 July 23, 2021, from https://en.wikipedia.org/wiki/Urinary_retention
Wikimedia Commons (2017, March 29) What is urinary incontinence? Retrieved 23:56 July 23, 2021 https://commons.wikimedia.org/wiki/File:Urinary_incontinence.webm
Wikipedia The Free Encyclopedia (2021, June 12) Pyuria. Retrieved 23:00 July 23, 2021, from https://en.wikipedia.org/wiki/Pyuria
Wikipedia The Free Encyclopedia (2021, June 8) Urinary retention. Retrieved 23:00 July 23, 2021, from https://en.wikipedia.org/wiki/Urinary_retention

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Health Assessment Guide for Nurses Copyright © by Ching-Chuen Feng; Michelle Agostini; and Raquel Bertiz is licensed under a Creative Commons Attribution 4.0 International License, except where otherwise noted.

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