Nursing Assessment for Gastrointestinal
History :
- What are the specific signs or symptoms and how long have they been present ?
- Have any nursing measures or prns been given ?
- Is the resident currently being monitored and/or treated for an infection ?
- Is nausea &/or emesis associated with a certain time of day or oral intake ?
- Is the resident eating and drinking as usual ?
- Is the resident tube fed? Number of cc’s of air or fluid in bulb ?
- Any history of GI problems? Ileus, bowel obstruction, impaction, gastritis, GI bleed ?
- Are there any recent (within past week) lab values or abdominal x-rays available ?
- What medications is the resident currently taking? Is the resident on Coumadin? If YES what is the most recent INR ?
- Is the resident on dialysis ?
- Is the resident allergic to any medications ?
- Are other residents currently being treated for the same symptoms ?
Physical :
- What are the current vital signs? (Accucheck if diabetic)
- Is the resident impacted on digital examination? Last BM ?
- Note contour of abdomen, bowel sounds, abdominal pain.
Response :
- If cause of GI symptom is known and treatment in place continue with medications and treatments as order.
- For new GI symptom complete evaluation and give prns as ordered.
Source : http://www.ltcpractice.com