GASTROINTESTINAL – Nursing Assessment Guideline

Whenever a resident has a gastrointestinal signs or symptoms the following assessment should be completed before the decision is made to either observe and treat with nursing measures and PRN medications or call the provider on call.

___________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:

13. What are the current vital signs? (Accucheck if diabetic)

14. Is the resident impacted on digital examination? Last BM?

15. Note contour of abdomen, bowel sounds, abdominal pain.

___________Response:

A. If cause of GI symptom is known and treatment in place continue with

medications and treatments as order.

B. For new GI symptom complete evaluation and give prns as ordered.

___________NOTIFICATION CATEGORIES:

Emergency: New, acute GI symptom accompanied by hypotension, hypertension, profound lethargy, decreased oral intake, chills.

Routine: GI symptom, not responding to nursing measures, present and/or worsening over several hours.

Revised 2/04