12.3 Gastrointestinal and Genitourinary Assessment

The gastrointestinal (GI) system is responsible for the ingestion of food and the absorption of nutrients. Additionally, the GI and genitourinary (GU) systems are responsible for the elimination of waste products.^[1] Therefore, during assessment of these systems, the nurse collects subjective and objective data regarding the underlying structures of the abdomen, as well as the normal functioning of the GI and GU systems.

Subjective Assessment

A focused gastrointestinal and genitourinary subjective assessment collects data about the signs and symptoms of GI and GU diseases, including any digestive or nutritional issues, relevant medical or family history of GI and GU diseases, and any current treatment for related issues.^[2] Table 12.3a outlines interview questions used to explore medical and surgical history, symptoms related to the gastrointestinal and genitourinary systems, and associated medications. Information gained from the interview process is used to tailor the subsequent physical assessment and create a plan for patient care and education.^[3]

Table 12.3a Interview Questions for Subjective Assessment of GI and GU Systems

Gastrointestinal

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. Additional associated questions include asking if bloody stools (hematochezia); dark, tarry stools ( melena); bloating (abdominal distention); or vomiting of blood (hematemesis) are occurring.

Nausea, vomiting, diarrhea, and constipation are common issues experienced by hospitalized patients due to adverse effects of medications or medical procedures. Read more details about commonly occurring gastrointestinal conditions in the “Elimination” chapter in Open RN Nursing Fundamentals. 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. Read additional information about fluid and electrolyte imbalances in the “Fluids and Electrolytes” chapter in Open RN Nursing Fundamentals.

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 in patients who are swallowing pills, liquid, or food and can advocate for treatment to prevent complications, such as unintended weight loss or aspiration pneumonia.^[4]

Genitourinary

The nursing assessment of the genitourinary system generally focuses on bladder function. Ask about urinary symptoms, including dysuria, 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 sensation. 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 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. 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 urinary incontinence, 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] Read additional information about commonly occurring genitourinary system alterations in the “Elimination” chapter in Open RN Nursing Fundamentals.

Life Span Considerations

Infants

Eating and elimination patterns of infants require special consideration based on the stage of development.

• Ask parents about feeding habits. Is the baby being breastfed or formula fed? If formula fed, how does the child tolerate the formula?
• To assess for urine output in infants and toddlers, assess the frequency of wet diapers and the daily number of wet diapers. In hospitalized infants and toddlers, the diapers may be weighed for precise measurements of urine output.
• Note that the expected abdominal contour of an infant is called protuberant, which means bulging.
• Assess the umbilical cord; it should dry and fall off on its own within two weeks of life.
• Observe for respiratory movement in the abdomen of the infant.

Children

The expected abdominal contour of a child is protuberant until about the age of 4. Children often cannot provide more information than “my stomach hurts”; they may have symptoms of decreased school attendance due to abdominal discomfort.

Older Adults

Constipation may be more common in older adults due to decreased physical mobility and oral intake. Urinary urgency, urinary frequency, urinary retention, nocturia, and urinary incontinence are also common concerns for older adults.

Objective Assessment

Physical examination of the abdomen includes inspection, auscultation, palpation, and percussion. Note that the order of physical assessment differs for the abdominal system compared to other systems. Palpation should occur after the auscultation of bowel sounds so that accurate, undisturbed bowel sounds can be assessed. The abdomen is roughly divided into four quadrants: right upper, right lower, left upper, and left lower (see Figure 12.3^[6]). When assessing the abdomen, consider the organs located in the quadrant you are examining.

In preparation for the physical assessment, the nurse should create an environment in which the patient will be comfortable. Encourage the patient to empty their bladder prior to the assessment. Warm the room and stethoscope to decrease tensing during assessment.

Inspection

The abdomen is inspected by positioning the patient supine on an examining table or bed. The head and knees should be supported with small pillows or folded sheets for comfort and to relax the abdominal wall musculature. The patient’s arms should be at their side and not folded behind the head, as this tenses the abdominal wall. Ensure the patient is covered adequately to maintain privacy, while still exposing the abdomen as needed for a thorough assessment. Visually examine the abdomen for overall shape, masses, skin abnormalities, and any abnormal movements.

• Observe the general contour and symmetry of the entire abdominal wall. The contour of the abdomen is often described as flat, rounded, scaphoid (sunken), or protuberant (convex or bulging).
• Assess for distention. Generalized distention of the abdomen can be caused by obesity, bowel distention from gas or liquid, or fluid buildup.
• Assess for masses or bulges, which may indicate structural deformities like hernias or related to disorders in abdominal organs.
• Assess the patient’s skin for uniformity of color, integrity, scarring, or striae. Striae are white or silvery elongated marks that occur when the skin stretches, especially during pregnancy or excessive weight gain.
• Note the shape of the umbilicus; it should be inverted and midline.
• Carefully note any scars and correlate these scars with the patient’s recollection of previous surgeries or injury.
• Document any abnormal movement or pulsations. Visible intestinal peristalsis can be caused by intestinal obstruction. Pulsations may be seen in the epigastric area in patients who are especially thin, but otherwise should not be observed.^[7],[8]

Auscultation

Auscultation, or the listening of the abdomen, follows inspection for more accurate assessment of bowel sounds. Use a warmed stethoscope to assess the frequency and characteristics of the patient’s bowel sounds, which are also referred to as peristaltic murmurs.

Begin your assessment by gently placing the diaphragm of your stethoscope on the skin in the right lower quadrant (RLQ), as bowel sounds are consistently heard in that area. Bowel sounds are generally high-pitched, gurgling sounds that are heard irregularly. Move your stethoscope to the next quadrant in a clockwise motion around the abdominal wall.

It is not recommended to count abdominal sounds because the activity of normal bowel sounds may cycle with peak-to-peak periods as long as 50 to 60 minutes.^[9] The majority of peristaltic murmurs are produced by the stomach, with the remainder from the large intestine and a small contribution from the small intestine. Because the conduction of peristaltic murmur is heard throughout all parts of the abdomen, the source of peristaltic murmur is not always at the site where it is heard. If the conduction of peristaltic sounds is good, auscultation at a single location is considered adequate. ^[10]

Hyperactive bowel sounds may indicate bowel obstruction or gastroenteritis. Sometimes you may be able to hear a patient’s bowel sounds without a stethoscope, often described as “stomach growling” or borborygmus. This is a common example of hyperactive sounds. Hypoactive bowel sounds may be present with constipation, after abdominal surgery, peritonitis, or paralytic ileus.  As you auscultate the abdomen, you should not hear vascular sounds. If heard, this finding should be reported to the health care provider.^[11],[12]

Palpation

Palpation, or touching, of the abdomen involves using the flat of the hand and fingers (not the fingertips) to detect palpable organs, abnormal masses, or tenderness^[13] (see Figure 12.4 ^[14]). When palpating the abdomen of a patient reporting abdominal pain, the nurse should palpate that area last. Light palpation is primarily used by bedside nurses to assess for musculature, abnormal masses, and tenderness. Deep palpation is a technique used by advanced practice clinicians to assess for enlarged organs. Lightly palpate the abdomen by pressing into the skin about 1 centimeter beginning in the RLQ. Continue to move around the abdomen in a clockwise manner.

Palpate the bladder for distention. Palpate gently from umbilicus down toward the pelvis feeling for a full bladder. The bladder is not normally palpable, but a distended bladder may reach the umbilicus. A full bladder presents as a pelvis mass, which is typically regular, smooth, firm, and oval-shaped. It arises in the midline. Note the patient response to palpation, such as pain, guarding, rigidity, or rebound tenderness. Voluntary guarding refers to voluntary contraction of the abdominal wall musculature, usually the result of fear, anxiety, or the touch of cold hands. Involuntary guarding is the reflexive contraction of overlying abdominal muscules as the result of peritoneal inflammation. Rigidity refers to involuntary contraction of the abdominal musculature in response to peritoneal inflammation, a reflex the patient cannot control.^[15] Rebound tenderness is another sign of peritoneal inflammation or peritonitis. To elicit rebound tenderness, the clinician maintains pressure over an area of tenderness and then withdraws the hand abruptly. If the patient winces with pain upon withdrawal of the hand, the test is positive.^{[16],[17], [18]}

Note: If the patient has a Foley catheter in place, additional assessments are included in the “Facilitation of Elimination” chapter.

Percussion

You may observe advanced practice nurses and other health care providers percussing the abdomen to obtain additional data. Percussing can be used to assess the liver and spleen or to determine if costovertebral angle (CVA) tenderness is present, which is related to inflammation of the kidney.

See Table 12.3b for a comparison of expected versus unexpected findings when assessing the abdomen.

Table 12.3b Expected Versus Unexpected Gastrointestinal and Genitourinary Assessment Findings