Nursing Assessment for Gastrointestinal

Nursing Assessment for Gastrointestinal

History :
  1. What are the specific signs or symptoms and how long have they been present ?
  2. Have any nursing measures or prns been given ?
  3. Is the resident currently being monitored and/or treated for an infection ?
  4. Is nausea &/or emesis associated with a certain time of day or oral intake ?
  5. Is the resident eating and drinking as usual ?
  6. Is the resident tube fed? Number of cc’s of air or fluid in bulb ?
  7. Any history of GI problems? Ileus, bowel obstruction, impaction, gastritis, GI bleed ?
  8. Are there any recent (within past week) lab values or abdominal x-rays available ?
  9. What medications is the resident currently taking? Is the resident on Coumadin? If YES what is the most recent INR ?
  10. Is the resident on dialysis ?
  11. Is the resident allergic to any medications ?
  12. Are other residents currently being treated for the same symptoms ?

Physical :
  1. What are the current vital signs? (Accucheck if diabetic)
  2. Is the resident impacted on digital examination? Last BM ?
  3. Note contour of abdomen, bowel sounds, abdominal pain.

Response :
  1. If cause of GI symptom is known and treatment in place continue with medications and treatments as order.
  2. For new GI symptom complete evaluation and give prns as ordered.


Source : http://www.ltcpractice.com