GASTROINTESTINAL ASSESSMENT RETDEM:
- Good morning po, I am RR, The nurse assigned to this patient today.
- For today, I will be conducting a gastrointestinal assessment for the patient. Assessing the
abdomen of the patient. The patient will have to do a different position for this
assessment. The patient should be informed of the different positions that had to be done
to avoid the patient from feeling any discomfort or anxiety.
- Before entering the room, I will perform hand hygiene through handwashing technique
and observe other appropriate infection control procedures like wearing Personal
Protective Equipment (PPE) if necessary and ensuring that the patient’s bed is clean, and
that the equipment needed like the stethoscope are disinfected.
INTRODUCTION:
Good morning po, I am nurse ____, and I will be your nurse for today.
VERIFY THE PATIENT’S IDENTITY:
Pwede ko po bang malaman kung ano po yung buong pangalan niyo? At ang iyong kaarawan
po?
EXPLAIN THE PROCEDURE TO THE PATIENT:
Bago po tayo mag-simula ipapaliwanag ko po muna yung gagawin ko. Ngayon po, Ieexamine ko
po yung abdomen niyo or yung tiyan niyo po, at para matignan po natin ang kalagayan ng
digestive system ninyo at kahit papaano po ay ang urinary system din. Bukod po doon malalaman
din at makikita natin kung meron kayong pamamaga or bukol na possible maging cause of
concern po.
Para po sa mga tests na gagawin ko sa inyo kinakailangan ilagay yung kamay ko sa abdomen
niyo, at gagamit din po ako ng stethoscope, penlight, at pati na din po ng tape measure. Okay
lang po ba yon?
HISTORY OF THE PATIENT:
1. May nararanasan po ba kayo pananakit sa tyan ninyo?
a. If meron ask the OLD CARTS
i. Onset, location, duration, characteristics, alleviating, radiation, treatmens,
and severity.
2. Bukod po doon gusto ko lang kamustahin yung bowel habits niyo, gano po kayo kadalas
dumumi?
a. IF THERE ARE ANY CHANGES; WHEN WAS YOUR LAST BOWEL MOVEMENT;
URINATION (MALE PX)
3. Bukod po doon nakaranas po ba kayo ng diarrhea or constipation?
4. In terms naman po sa pagkain, kamusta naman po yung appetite ninyo?
a. Has there been any changes
b. Before po ba mabilis po ba kayong mabusog?
RR
, c. May pagbabago po ba recently sa appetite ninyo?
5. Food allergies.
a. May mga food allergies po ba kayo, or yung mga bawal po ninyo kainin?
6. Ma’am naaalala niyo po ba yung kinain niyo for the last 24 hours po?
a. Breakfast, Lunch, Meryenda, Dinner
7. Previous problems and treatments.
a. If the px has any memory of assessment re abdomen.
PATIENT PRIVACY:
Okay po, isasara ko lang po yung kurtina para po may privacy po tayo habang ginagawa ko po
yung physical exam sainyo.
ASSESSMENT PHASE:
1. Assist patient to a supine position. Place a small pillow under the head and beneath the
knees while the hands on the side or folded across the chest.
a. To relax abdominal muscle and for the comfort and relaxation of the px.
2. Expose the abdomen from the xiphoid process to the level of the symphysis pubis.
Ma’am for the first assessment po kailangan po na nakahiga po kayo at need ko din po kayo
lagyan ng unan sa ilalim ng tuhod niyo po, assist ko na po kayo.
Next naman po ma’am kinakailangan ko po iexpose yung abdomen niyo po.
INSPECTION:
Ang una ko pong gagawin ay iinspect ko lang po yung abdomen niyo po or yung tyan niyo.
Inspect the abdomen for Skin Integrity
1. While at the patient’s side, sit or bend down to view the contour of the abdomen.
2. Ask the patient to take a deep breath and hold it.
a. Pwede po ba kayong huminga ng malalim.
3. Assess the symmetry of contour while standing at the foot of the bed.
a. Pwede po ba kayong huminga ng malalim.
4. If distention is present, measure the abdominal girth by placing a tape around the
abdomen and measure at the level of the umbilicus.
a. For the next test po pwede po ba kayong tumayo para po mameasure lang natin
yung abdomen niyo and to make sure na wala pong any distention.
5. Observe abdominal movements associated with respiration, peristalsis, or aortic
pulsations using pen light.
a. Okay po sir, higa na po ulit kayo, assist ko na po kayo. Next naman po sir
ioobserve ko lang po yung pag galaw ng tyan niyo, relax lang po.
RR
- Good morning po, I am RR, The nurse assigned to this patient today.
- For today, I will be conducting a gastrointestinal assessment for the patient. Assessing the
abdomen of the patient. The patient will have to do a different position for this
assessment. The patient should be informed of the different positions that had to be done
to avoid the patient from feeling any discomfort or anxiety.
- Before entering the room, I will perform hand hygiene through handwashing technique
and observe other appropriate infection control procedures like wearing Personal
Protective Equipment (PPE) if necessary and ensuring that the patient’s bed is clean, and
that the equipment needed like the stethoscope are disinfected.
INTRODUCTION:
Good morning po, I am nurse ____, and I will be your nurse for today.
VERIFY THE PATIENT’S IDENTITY:
Pwede ko po bang malaman kung ano po yung buong pangalan niyo? At ang iyong kaarawan
po?
EXPLAIN THE PROCEDURE TO THE PATIENT:
Bago po tayo mag-simula ipapaliwanag ko po muna yung gagawin ko. Ngayon po, Ieexamine ko
po yung abdomen niyo or yung tiyan niyo po, at para matignan po natin ang kalagayan ng
digestive system ninyo at kahit papaano po ay ang urinary system din. Bukod po doon malalaman
din at makikita natin kung meron kayong pamamaga or bukol na possible maging cause of
concern po.
Para po sa mga tests na gagawin ko sa inyo kinakailangan ilagay yung kamay ko sa abdomen
niyo, at gagamit din po ako ng stethoscope, penlight, at pati na din po ng tape measure. Okay
lang po ba yon?
HISTORY OF THE PATIENT:
1. May nararanasan po ba kayo pananakit sa tyan ninyo?
a. If meron ask the OLD CARTS
i. Onset, location, duration, characteristics, alleviating, radiation, treatmens,
and severity.
2. Bukod po doon gusto ko lang kamustahin yung bowel habits niyo, gano po kayo kadalas
dumumi?
a. IF THERE ARE ANY CHANGES; WHEN WAS YOUR LAST BOWEL MOVEMENT;
URINATION (MALE PX)
3. Bukod po doon nakaranas po ba kayo ng diarrhea or constipation?
4. In terms naman po sa pagkain, kamusta naman po yung appetite ninyo?
a. Has there been any changes
b. Before po ba mabilis po ba kayong mabusog?
RR
, c. May pagbabago po ba recently sa appetite ninyo?
5. Food allergies.
a. May mga food allergies po ba kayo, or yung mga bawal po ninyo kainin?
6. Ma’am naaalala niyo po ba yung kinain niyo for the last 24 hours po?
a. Breakfast, Lunch, Meryenda, Dinner
7. Previous problems and treatments.
a. If the px has any memory of assessment re abdomen.
PATIENT PRIVACY:
Okay po, isasara ko lang po yung kurtina para po may privacy po tayo habang ginagawa ko po
yung physical exam sainyo.
ASSESSMENT PHASE:
1. Assist patient to a supine position. Place a small pillow under the head and beneath the
knees while the hands on the side or folded across the chest.
a. To relax abdominal muscle and for the comfort and relaxation of the px.
2. Expose the abdomen from the xiphoid process to the level of the symphysis pubis.
Ma’am for the first assessment po kailangan po na nakahiga po kayo at need ko din po kayo
lagyan ng unan sa ilalim ng tuhod niyo po, assist ko na po kayo.
Next naman po ma’am kinakailangan ko po iexpose yung abdomen niyo po.
INSPECTION:
Ang una ko pong gagawin ay iinspect ko lang po yung abdomen niyo po or yung tyan niyo.
Inspect the abdomen for Skin Integrity
1. While at the patient’s side, sit or bend down to view the contour of the abdomen.
2. Ask the patient to take a deep breath and hold it.
a. Pwede po ba kayong huminga ng malalim.
3. Assess the symmetry of contour while standing at the foot of the bed.
a. Pwede po ba kayong huminga ng malalim.
4. If distention is present, measure the abdominal girth by placing a tape around the
abdomen and measure at the level of the umbilicus.
a. For the next test po pwede po ba kayong tumayo para po mameasure lang natin
yung abdomen niyo and to make sure na wala pong any distention.
5. Observe abdominal movements associated with respiration, peristalsis, or aortic
pulsations using pen light.
a. Okay po sir, higa na po ulit kayo, assist ko na po kayo. Next naman po sir
ioobserve ko lang po yung pag galaw ng tyan niyo, relax lang po.
RR
