8.5 : Assessment of the Gastrointestinal System I: Subjective Data

Assessing the gastrointestinal (GI) system is a complex process that begins with collecting subjective data. This data, collected through patient interviews, provides crucial insights into the patient's health history, perception patterns, and lifestyle habits, all contributing significantly to GI health.

Health History

The initial step in assessing the GI system is obtaining a comprehensive health history. This includes inquiring about the patient's history or presence of problems related to GI functioning. Critical symptoms to explore include abdominal pain, nausea, vomiting, changes in appetite, indigestion, bloating, hematemesis, and trouble swallowing. It is also vital to review the patient's bowel habits, such as diarrhea, constipation, melena, rectal bleeding, and excessive gas.

Evaluating the patient's weight history is another critical aspect. Any unexplained or unplanned weight loss or gain within the past 6 to 12 months should be explored in detail. A history of chronic dieting and repeated weight loss and gain could indicate underlying issues affecting the GI system.

Medications

Assessment of the patient's past and current use of medications is imperative. It involves inquiring about the purpose of medication, dosage and frequency, duration of use, administration route, efficacy, and potential adverse reactions. Various medications can cause side effects in the GI system and affect drug absorption and effectiveness. For instance, NSAIDs may cause upper GI bleeding, particularly in older individuals.

Summary

Assessing the GI system starts with subjective data collection from patient interviews, focusing on health history, GI symptoms, bowel habits, weight history, and medication use. This process helps identify factors like abdominal pain, digestive issues, and medication side effects that could impact gastrointestinal health and functionality, guiding further diagnostic steps.