Assessment and Observation of the Gastrointestinal, Urinary and Reproductive Systems

Learning objectives for this chapter

By the end of this chapter, we would like you:

-To describe the basic anatomy and physiology of the gastrointestinal, urinary and male / female reproductive systems.

-To explain how to collect a focused health history related to the gastrointestinal, urinary and male / female reproductive systems.

-To explain how to undertake a physical examination of the gastrointestinal, urinary and male / female reproductive systems.

-To recognise the common problems / conditions related to the gastrointestinal, urinary and male / female reproductive systems, and their typical clinical findings, to enable differential diagnosis.

-To describe the variety of special assessment techniques which may be used in the physical examination of the gastrointestinal, urinary and male / female reproductive systems.

Fundamental anatomy and physiology of the gastrointestinal and urinary systems

The structures which comprise the gastrointestinal system include the mouth, oesophagus, stomach, duodenum, colon and the rectum, plus the accessory organs. The oesophagus carries food from the mouth to the stomach. The stomach is a hollow, muscular organ which breaks down food using gastric acid into a substance called chyme. The chyme is released progressively through the pyloric sphincter and into the duodenum, and subsequently the colon. It is moved through the intestines by rhythmic contractions of the intestinal muscles, called peristalsis. In the intestines, key nutrients, electrolytes and water are absorbed from the chyme, leaving nothing but waste products. These are eventually excreted from the body via the rectum, as stool.

There are a number of accessory organs which support the function of the digestive system. The liver, the largest organ in the body, is located directly beneath diaphragm, on the right hand side; it performs a number of key roles including:

• Metabolising protein, carbohydrate and fat.
• Storing glucose, a substance the body uses for energy.
• Storing other vitamins and minerals, including iron, copper and B-complex vitamins.
• Detoxification of substances.
• Producing and secreting bile, which has a role in digestion.
• The transfer of bilirubin, another substance with a role in digestion, from the blood.
• Producing clotting factors and fibrinogen, which help the blood to clot.
• Synthesis of many plasma proteins.

The gallbladder is another accessory organ of the gastrointestinal system; it stores bile produced by the liver. Another organ, the pancreas, secretes a number of substances to support the metabolism of carbohydrates, proteins and fats. The last accessory organ in the abdomen, the spleen, has immune function and also supports the production and maintenance of the body’s blood.

The abdomen also contains the urinary system. The urinary system functions to remove water-soluble wastes from the blood, and eventually from the body. The key organs in the urinary system are the kidneys, which filter the blood to remove waste products. Once liquid waste, now in the form of urine, has been filtered by the kidneys, it travels down two muscular tubes called the ureters and into the bladder. When the bladder volume reaches between 300 millilitres and 450 millilitres, the person experiences the urge to void and urine exits the body via another tube called the urethra.

Gastrointestinal and urinary systems – focused health history

When assessing a patient’s gastrointestinal and urinary systems, the nurse must commence by collecting a health history. This involves collecting data about:

• Present health status
  • Chronic illnesses
  • Current medications
  • Alcohol consumption
  • Tobacco smoking (past and current)
  • Bladder and bowel habits
• Past medical history
  • Injuries to, or illnesses of, the gastrointestinal or urinary system organs
• Family history of diseases affecting the gastrointestinal / urinary systems

In some cases, a person will present with a specific problem related to their gastrointestinal / urinary system/s.

Abdominal pain is a particularly significant symptom indicating dysfunction in the gastrointestinal / urinary systems. The location, quality, quantity, chronology, associated manifestations and aggravating / alleviating factors a patient experiences can provide important information about the cause of this pain – and allow the patient’s health care team to make a differential diagnosis. Review the information in the following table:

Cause of Pain	Factors Enabling Differential Diagnosis
Gastro-oesophageal reflux disease (GORD)	Pain is often described as “gnawing”, “burning” pain is located in the mid-epigastric region, may radiate to the jaw; pain may be associated with weight loss; pain is aggravated by a recumbent position; pain is alleviated by a high-sitting position, antacids, etc.
Gastritis	Pain is often described as a “constant burning” pain is located in the epigastric region; pain may be associated with nausea / vomiting, diarrhoea, fever; pain is aggravated by alcohol, food, salicylates; pain is alleviated by antacids; on assessment, a nurse will often find hyperactive bowel sounds.
Peptic ulcer	Pain is often described as “gnawing”, “burning” pain is located in the epigastric, back and upper abdominal regions; pain may be associated with nausea, vomiting, weight loss; pain is aggravated by stress, alcohol, food or an empty stomach; pain is alleviated by antacids; on assessment, a nurse will often find epigastric tenderness.
Pancreatitis	Pain is often described as “knife-like”, it may be mild to severe, usually has a sudden onset; pain is located in the left upper quadrant and epigastric regions, may radiate to the back; pain may be associated with nausea / vomiting, diaphoresis; pain is aggravated by lying supine; pain may be alleviated by leaning forward; on assessment, a nurse will often find abdominal distention, hyperactive bowel sounds, diffuse abdominal rebound, etc.
Appendicitis	Pain is often described as “colicky”, progressing to constant; pain is located in the umbilical region, progressing to the right lower quadrant; pain may be associated with vomiting, constipation, fever; pain is aggravated by movement, coughing; pain may be relieved by lying still.
Cholecystitis / cholelithiasis	Pain is often described as “colicky”, progressing to constant; pain is located in the right upper quadrant, may radiate to the scapula; pain is associated with nausea / vomiting, jaundice; pain may be aggravated by fatty foods, medications; on assessment, a nurse will often find tenderness in the right upper quadrant.
Diverticular disease	Pain is often described as “intermittent cramping” pain is located in the left lower quadrant; pain is often associated with constipation, diarrhoea; pain is aggravated by eating; pain may be relieved by defecation, passing flatus.
Irritable bowel disease	Pain is often described as “crampy”, “sharp” or “burning” pain is usually located in the left and right lower quadrants; pain is often associated with mucus in the stools; pain may be relieved by defecation; on assessment, a nurse will often find the colon is tender on palpation.
Intestinal obstruction	Pain is often described as “colicky”, with a sudden onset; pain may be localised or generalised; pain may be associated with vomiting, constipation; on assessment, a nurse will often find hyperactive bowel sounds or hypoactive bowel sounds.
Urinary tract infection	Pain is often described as “colicky”, with a progressive onset; pain may be localised or generalised; pain may be associated with nausea / vomiting, fever, haematuria, urge / frequency of urination, urination, etc.; pain is relieved by antibiotic administration.
Nephrolithiasis	Pain is often described as “colicky”, with a progressive onset; pain may be localised or generalised; pain may be associated with nausea / vomiting, haematuria; pain is relieved by the passing of the calculus.

Gastrointestinal and urinary systems – physical examination

Once a health history of the gastrointestinal / urinary systems has been obtained a nurse may commence a physical examination of the patient’s gastrointestinal / urinary systems:

• Observe the client’s general behaviour and positioning.
• Inspect the abdomen for surface characteristics, contour, surface movements.
• Auscultate the abdomen for bowel sounds.
• Palpate the abdomen for tenderness, muscle tone.
• Percuss the abdomen.

Special assessment techniques for the gastrointestinal and urinary systems

There are a number of special assessment techniques particular to the gastrointestinal and urinary systems:

• Testing for rebound tenderness. The nurse presses their fingers deeply into the client’s abdomen, and then rapidly withdraws their fingers.
• Ballottement, to identify a floating mass. If a nurse palpates a mass in the abdomen, the nurse should place one hand perpendicular to the patient’s abdomen and push towards the mass with their fingertips at a 90 angle.

Fundamental anatomy and physiology of the reproductive system

The fundamental purpose of the reproductive system is to facilitate reproduction. The reproductive system is the only system in the body where there are marked differences between males and females:

• Male reproductive system: The male reproductive system consists of the penis, scrotum, testes and a series of associated ducts and glands. The male reproductive system is under hormonal control; from puberty and for the remainder of his life, a male produces hormones which stimulate spermatogenesis. Spermatogenesis occurs in the testes, which are suspended outside the body cavity to ensure sperm production occurs at an ideal temperature, slightly below body temperature. Sperm, mixed with a variety of substances from the ducts and glands, leaves the body via the urethra during ejaculation.
• Female reproductive system: The female reproductive system consists of the vagina, uterus, fallopian tubes and ovaries, and external structures. The female reproductive cycle is under hormonal control; from the time of puberty, in a regular twenty-eight-day cycle, the lining of the endometrium in the uterus progressively thickens, ovulation occurs, and if no fertilisation takes place, the endometrium and oocyte are shed during menstruation.

Reproductive system – focused health history

As always, when assessing a patient’s reproductive system, the nurse must commence by collecting a health history. This involves collecting data about:

• Present health status
  • Chronic illnesses
  • Current medications
  • Self-examination, or professional examination, of the genetalia
• Injuries to, or illnesses of, the reproductive system organs
• Family history of diseases affecting the reproductive systems
• Sexual history
• Obstetric history

In some cases, a person will present with a specific problem related to their reproductive system.

Reproductive system – physical examination

Once a reproductive health history has been obtained, as described in the previous section of this chapter, a nurse may commence a physical examination of the patient’s reproductive system:

For the male reproductive system:

• Inspect and palpate the external structures – including the penis surface, scrotum and perineum.
• Palpate the internal structures – including the testes, epididymis, vas deferens.

For the female reproductive system:

• Inspect and palpate the external structures – including the labia majora, labia minora, clitoris, urethral meatus, vaginal introitus, perineum.
• Inspect and palpate the internal structures – including the glands and the vaginal wall / uterus. As internal structures, these are ONLY assessed if indicated.

Special assessment techniques for the reproductive system

There are a number of special assessment techniques particular to the reproductive system:

• For women, a speculum examination; this involves inserting a plastic or metal speculum into the vaginal introitus to separate the vaginal walls and visualise – and, perhaps, obtain smears for further testing from – the internal structures below the uterus.
• For men, an internal examination of the prostate gland. This involves a clinician inserting a finger into the rectum to assess the location and size of the prostate gland.

Differential diagnosis in the reproductive system

When assessing a patient’s reproductive system, there are a number of common problems and conditions a nurse may identify:

• Bacterial vaginosis (females) – a condition resulting in an alteration in normal vaginal flora, including its replacement with pathogenic bacteria.
• Chlamydia – an infection with the Chlamydia trachomatis bacteria. May occur in males or females.
• Gonorrhoea – an infection with the Neisseria gonorrhoeae bacteria. May occur in males or females.
• Syphilis – an infection with the Treponema pallidum bacteria. May occur in males or females.
• Herpes genitalis – an infection with the Herpes simplex virus, Type 1 or Type 2. May occur in males or females.
• Pelvic inflammatory disease (females) – a polymicrobial infection of the upper reproductive tract structures (e.g. endometrium, fallopian tubes, ovaries, uterine wall, ligaments, etc.)
• Epididymitis (males) – inflammation of the epididymis and the vas deferens.
• Endometriosis (females) – the growth of uterine tissue outside the uterus.
• Uterine leiomyomas / fibroids (females) – benign overgrowths of tissue in / around the uterus.
• Testicular torsion (males) – twisting of the testicle and spermatic cord, resulting in acute tissue hypoxia.
• Hydrocele (males) – an accumulation of fluid in the scrotum.
• Benign prostatic hyperplasia (males) – the enlargement of the prostate without the presence of cancer.

Conclusion

It is important that nurses are able to accurately and comprehensively assess these systems, and this chapter has introduced the fundamental knowledge and skills nurses require to do so. This chapter has explored the fundamental anatomy and physiology of the gastrointestinal, urinary and male / female reproductive systems. This chapter has also explained the processes involved in collecting a general health history for the gastrointestinal, urinary and male / female reproductive systems, and in performing a physical examination of these systems. This chapter also considered a number of special observation and assessment techniques which may be used in the physical examination of the gastrointestinal, urinary and male / female reproductive systems, and it discussed performing differential diagnosis relevant to these systems.