消化系统疾病患者的 健康评估 Health Assessment of The Digestive System 徐丽华 上海交通大学护理学院 2006年4月26日

学习目标 熟悉肠胃系统的正常功能 认识肠胃系统的异常表现 掌握肠胃系统的评估要点 熟悉肠胃系统评估技巧 分辨不同年纪、性别、疾病谱在消化系统的表现

GI System Assessment 消化系统评估 健康史: 生活背景Biographical and demographic data 目前健康状况 Current Health 过去健康病史 Past Health history 家族史 Family Health 心理社会因素 Psychosocial Factors 系统回顾 Review of system

Demographic Data 背景资料评估 Gender Age Marital Status Working condition Women (calcium), elderly (inadequate food intake, gastric ulcer, colon cancer), teenagers (Duodenal ulcers, gastric cancers) may have different health problem and nutritional needs.

Current Health Assessment 目前健康评估 评估主诉是否出现： 恶心、呕吐 吞咽困难：梗阻与疼痛 不消化 ：反酸或嗳气 腹痛 呕血、便血 腹泻、便秘 腹水 黄疸 体重及食欲改变. Nausea/vomiting: when, how log? Related to food intake? Food relieve or worsen the discomfort? Vomitus contain undigested food or bile, quantity, pain associate with vomiting? Nausea、vomiting：性质、次数、喷射性？自主神经功能紊乱（出汗、头疼、头晕、面色苍白、心率快、血压下降） Indigestion: Burping or burning sensation, related to food intake, which food relieve and worsen the condition, take any antacids? Abdominal pain: rapid or gradual, intensity of pain, pain increase in the past few hours? Radiate? Worsen or improve with movement? Food exacerbate or alleviate ? Diarrhea: how many times per day? Liquid or solid, color? Black or bloody? Pain associate with defecation? Abdominal bloating or cramping? Greasy stool (malabsorption) Appetite change

Past Health History 过去病史 Bleeding-iron deficiency anemia Liver Disease: protein malnutrition Peptic Ulcer With bleeding Jaundice Gallbladder sisease Pancreatitis Cancer Change of bowel habits Tarry stools Unexplained weight loss or gain

Health History of The GI System Health Perception-health management pattern Nutritional-metabolic pattern Elimination pattern Activity-exercise pattern Sleep-Rest Pattern Congitive-preception pattern Self-Perception, self-concept pattern Role-relationship pattern Sexuality-reproductive pattern Coping-stress tolerance pattern Value-belief pattern Lewis, 2004, p.955

Assess for Medications 药物评估 Use of Aspirin, NAISD (Nonsteroidal anti-inflammatory drugs) –gastritis/bleeding是否使用阿斯匹林，非激素类止痛药，胃出血 Antacids: type and frequency 制酸剂，种类、频率 Laxatives or stool softeners? 软便剂 Dietary Supplement: vitamins,minerals, herbs, amino acids 食品补充，维生素、草药、蛋白质

Assessment for Allergies 评估过敏史 Food allergies: hives or dyspnea Food intolerance: GI abdominal cramping, flatulence, or diarrhea (lactose intolerance) Comment food allergies items: nuts, shellfish, cow’s milk, food additives

Assessment for Family History GI problem may associate with family history and environment factors. Ulcerative colitis 溃疡性结肠炎 Crohn’s Disease 克罗恩病 Alcoholism 酗酒 Liver diseases 肝脏疾病 Family history of DM, anemia, jaundice, hepatitis, Pancreatitis, obesity, irritable bowel syndrome. 糖尿病家族史、贫血、黄疸、肝炎、胰脏炎、肥胖、小肠激惹症候群

Psychosocial History 心理社会病史 Occupation: environmental toxins (lead, mercury, carbon tetrachloride) Travel: Pathogens (protozoa, parasites),eating raw shellfish, swimming in polluted water Diet habits change

Assessment of GI System Abdomen Inspection 视诊 skin intact, smooth 皮肤完整、平滑 Contour: flat, rounded, no distention or irregular contour 形状，腹胀、不规则形状 Rashes, discoloration, scares, petechiae, striate, dilated veins 红疹、变色、疤痕、青紫、横纹、扩张静脉 Peristaltic movement if pt has obstruction of the bowel 小肠阻塞可见肠蠕动运动 Abdominal pulsation 腹部可见脉动

Review of System 系统回顾 Mouth:oral lesions, excessive salivation, mouth dryness, oral ulcer Dental cavity: floss usage Water supply with fluoridate? Dentist for teeth cleaning Periodontal disease Trouble tasting, chewing or swallowing?

Assessment of the GI system Mouth Lips: symmetry, color, hydration, lesions, nodules, position of teeth (malocclusion), dental caries, color of mucosa and gums, swelling or lesions, leukoplakis lesion （白斑） Tonsils: redness, swelling, lesions, ulcers, Tongue: color, moisture, atrophy, abnormal coating, swelling, lesions, symmetry movement, difficulty to swallow (Dysphagia 吞咽困难) Use tongue blade to scrape leukoplakis if the white patches do not scrape off, refer the client for further work-up to rule out cancerous lesions.

Assessment for Oral Disorders Stomatitis: Aphthous ulcer (unknown), 口腔溃疡 Herpes Simplex (HSV infection), 疱疹 Oral candidiasis-Thrush (Candida Albicans fungus infection)念珠球菌感染 Assess for immunosuppression, prolonged antibiotic use, pain, tenderness, bleeding, oral intake/nutrition （免疫低下者，长期使用抗生素者、疼痛、压痛、出血、营养进食情况）

Assessment of Oral Disorder Premalignant tumor：恶性肿瘤前期 Leukoplasia 白斑 Erythroplakia 红斑 Tumor of the oral cavity: Basal cell or Squamous cell carcinoma Risk factor: tobacco and long term alcohol consumption, Very Hot beverages, 槟榔

评估吞咽困难 （Dysphagia） 口腔疾病： 吞咽时梗阻与疼痛，感觉吞咽时间延长， 口腔溃疡 扁桃体炎 咽炎 咽壁浓肿、肿瘤 急性喉咽 喉头水肿 喉癌

Assessment of the Salivary Glands 唾液腺 Sings of inflammation Inactivity of the gland caused by medication or prolonged NG tube, NPO Dry mouth Bad breath order from bacteria accumulated in the mouth due to insufficient salivary.

Assessment of Esophagus 食管评估 Dysphagia 吞咽困难 Regurgitation 反流: reflux can affect respiratory tract Pain 疼痛 Heartburn or pyrosis 烧灼感 Dysphagia: difficult to swallow, causes (mechanical obstruction, cardiovascular abnormalities, neuralgic disease-stroke, multiple sclerosis) Regurgitation Pain Heartburn or pyrosis : indigestion , sensation of warmth and burning in the lower retrosternal midline and radiate upward to neck, due to incompetent lower esophagel sphincter “waves, cramping or knotting” pain.

评估吞咽困难（Dysphagia） 食管疾病 食管炎 食管溃疡 食管狭窄 食管异常或先天性异常 食管裂孔疝 喷门口失驰缓症 食管癌

Assessment of GI System Abdomen Auscultation: Air and fluid move through the GI tract, soft clicks and gurgles q5-15 sec. Normal bowel sound: irregular 4-5/min Hyperactivity: Loud, high-pitch sound of the GI tract, > 10/min-GI bleeding, acute gastroenteritis 3. Hypoactivity: few bowel sound (listen for 5 minutes or 1 minute each quadrant (absence of bowel sounds does not mean absence of bowel peristalsis)

Assessment of GI System Abdomen Percussion/Palpation 疼痛部位、性质（钝、绞痛）腹肌柔软度、是否出现压痛或反跳痛、剧烈绞痛拌有高肠鸣音（肠梗），腹部包块、液波震颤如门脉高压腹水、腹胀、阵痛、是否反射至右肩（胆结石），或后背及中上腹（胰腺炎），右下腹反跳痛（阑尾） 炎症刺激，腹壁是否紧张痉挛，如穿孔可导致腹肌高度紧张 （ abdominal rigidity）、强直“板样腹”

腹部疼痛的病因与特征 －1 腹部脏器扭转或阻塞 （Organ obstruction or twisting）: intermittent collicky pain, 间断性绞痛 under umbilicus associate with small bowel在脐部位与小肠有关. distended abdomen with no flatus or bowel movement, 腹胀，缺乏排气或肠蠕动 bowel sound may change from high pitch to absent 肠鸣音由高音到消失

腹部疼痛的病因与特征－2 腹部脏器炎症：Peritoneal inflammation (Perforated ulcer, ruptured spleen, ruptured appendix) Steady aching pain over area of inflammation, 在炎症部位疼痛 pain increased with motion, 活动时疼痛增加 may associate with shock if pain is severe 过度疼痛时可能与休克有关

腹部疼痛的病因与特征－3 腹部脏器血管狭窄或梗阻 Vascular Catastrophe (Aortic aneurysm or mesenteric infarction) 2-3 days mild tomoderate pain and hyperperistalsis followed by severe abdominal pain 中等度疼痛，肠蠕动增加，腹部疼痛厉害 Back and flank pain are common with aortic aneurysms. 主动脉瘤常见后背或腰部疼痛

Assessment for Regurgitation 评估反流（反酸） 导因：炎症、溃疡、肿瘤使喷门扩约肌松弛，胃逆蠕动增加，使胃酸容易反流入口腔，侵蚀食管，容易引起酸性胃液反流入口，胸骨后烧灼感

Assessment of Vomiting 患者的呕吐物需要仔细评估量、色、性质、频率、反射性呕吐？诱发因素？是否带血样？是否呈咖啡色样液体，呕吐后生理变化 患者有哪些过去病史、现在疾病导致呕吐或呕血？ 食管、胃、十二指肠、粘膜、溃疡、癌症、胰胆疾病等因素需要评估

评估腹水 Assessment of Ascites 腹腔内过多液体积聚，分为浆液性、血性、浓性、乳糜性，依照腹水中的蛋白含量、比重、细胞量而区分。 引起腹水原因包括：肝硬化、重度肝炎、腹膜炎、癌症、心衰竭等。 评估腹水影响：呼吸、皮肤完整性、血清蛋白缺失、体重变化、行动、活动度，舒适程度

评估黄胆 Assessment of Jaundice 胆红素代谢障碍使血中胆红素浓度升高，渗入组织、皮肤、巩膜、粘膜，呈黄色。 正常血清总胆红素 8.55-17.1 umol/L (0.5-1mg/dl, 升高到34.2umol/L (2mg/dl), 临床可见黄胆。 评估：皮肤干燥、骚痒、外观影响，小便颜色深茶色

Assessment of the Liver and Spleen Hepatomegaly 肝脏肿大: enlargement of liver, liver edge > 1-2cm below costal margin (possible Hepatitis 肝炎, venous congestion 静脉充血, metastatic carcinoma肿瘤转移) Splenomegaly脾脏肿大: Enlargement of spleen (possible portal hypertension 门静脉高压, infection感染)

下胃肠道系统症状评估 分析： 时间：出现时间及持续，突发？是否与进食有关 性质与量：叙述疼痛性质，深、闷痛、弥散性疼痛，腹泻与血便性质 部位：反射其它部位，涉及肝脏、脾脏、阑尾区、直肠？ 诱因：压力、食物、药物 相关表现：生活影响、食物不耐受、黄疸、腹水、腹部绞痛等

下胃肠道健康评估 腹部评估：腹胀、肿块、对等性、明显的肠蠕动、脐或腹股沟疝气、肠鸣音、腹水、腹痛区是否反射性疼痛、反跳性疼痛（Rebound tenderness) 肛门与直肠： 痔疮、脱肛、皮肤完整性、红疹、溃疡、肛裂（Anal Fissure）、瘘管（Anal Fistula）、脓肿（Anorectal abscess）

Assessment of the Bowel Elimination 年龄与性别：Colorectal cancer 常见于年纪长者、男性 溃疡性结肠炎 Ulcerative colitis 常发生于中年白种人，犹太人 Diverticular disease 常见于已开发国家精制食物摄取较多

Assessment for Bowel Elimination Ascites 腹水 Diarrhea 腹泻 Constipation 便秘 Melena 便血 Pain in Rectal or Abdominal :腹部疼痛或肛门疼痛

Assessment of Diarrhea and Constipation Diarrhea: acute or chronic (> 2 months of diarrhea 评估腹泻后生理变化：渗透压升高、消化不完全、肠蠕动过快、肠内容物水份高、消化不完全 急性腹泻：与细菌感染有关、与进食感染源有关，包括菌痢

评估腹泻 Diarrhea 腹泻性质、频率、量。 是否腹痛及里急后重感？ 是否有肠粘膜破坏？ 浓样血便？水样便？ 饮食不洁？细菌感染？ 常见的致病菌为：大肠杆菌、沙门菌、轮状病毒、肠病毒、血吸虫等。可依可能的感染途径评估致病因素。

评估便血 消化道出血，由肛门排出，颜色与出血量、时间、部位有关。 下消化道出血，近直肠肛门部位，停留时间短：鲜红 上消化道出血，通过肠道，Hb 与肠道硫化物结合，形成黑色便 （Tarry Stool） 鉴别：肠道细菌感染或炎症，肠道肿瘤、息肉、痔疮、克罗恩病、肠套叠等。

评估便秘 Constipation 结肠性便秘：结肠内的机械梗阻，结肠蠕动减少、结肠痉挛 直肠性便秘：直肠肛周病变所致，生活习惯改变，排便习惯不正确，常服用泻药或灌肠，导致直肠粘膜感受器的敏感性降低， 常发生于老年人及长期卧床休息者。

Physical Assessment Annus and Rectum Assess for : Tenderness, 压痛 Masses, 肿块 hemorrhoids, 痔疮 Prolapsed, 脱垂 Rectal mucosa smooth, 直肠粘膜平滑 Stool negative for blood 便血阴性

Aging Patient GI Assessment 年长者肠胃系统评估 Mouth: Loss of teeth Decreased taste buds, decreased sense of smell 胃蕾减少，嗅觉下降 Decreased volume of saliva 唾液减少 Atrophy of gingival tissue 牙龈萎缩

Aging Patient GI Assessment 年长者肠胃系统评估 Esophagus 食管 Decreased tone and motility 降低张力及动力

Aging Patient GI Assessment 年长者肠胃系统评估 Abdominal Wall Thiner and less taut Decrese in number and sensitivity of sensory receptors More visible peristalsis Stomach: Decreased acid secretion, atrophy of gastric mucosa 降低胃酸分泌，胃粘膜萎缩

Aging Patient GI Assessment 年长者肠胃系统评估 Small Intestines :小肠 Decreased secretion of most digestive enzymes, 消化液分泌减少 Decreased moltility-complain of indigestion 动力降低，主述“不消化” Liver: 肝脏 Decreased size and lowered in position 降低尺寸及位置

Aging Patient GI Assessment 年长者肠胃系统评估 Large intestine, anus, rectum: 大肠、肛门、直肠 Decreased anal sphincter tone and nerve to rectal area-fecal incontinence 肛门扩约肌张力及神经传导下降，失禁 Decreased muscular tone, decreased motility-Flatulence, abdominal distension constipation, fecal impaction 肌肉张力下降，活动力降低，腹胀、便秘、粪便嵌塞

营养与消化系统评估的重要性 The importance of nutritional health and digestive assessment Nutritional health requires a functional gut to receive,transport, absorb, and metabolize nutrients. Interdependence assessment of the gastrointestinal tract and nutritional status

进行营养评估 Nutritional Health Assessment Dietary Intake食物摄取量：列出过去24小时所有的饮食摄取(Dietary intake recall) 参考食物建议摄取量（Recommended Daily Allowance） 计算健康者每日所需要的热量及蛋白质： 30－50 Calories/Kg 0.8-1.2 g of protein/Kg

Malnutrition 营养不良 Micronutrient Malnutrition 常见于慢性胰脏炎 （Chronic Pancreatitis), 小肠短小症 （short－bowel syndrome), Pressure ulcer 胃溃疡, Cancer 癌症, AIDS 艾滋病, Prior to gastric surgery

营养评估 收集病史，了解过去资料 健康现况 现性健康历史 家族史 社会心理支持

总结： 肠胃系统评估包括口腔、食管、胃肠道、肝脾腹部器官、大肠、直肠、肛门等器官 消化系统的健康与营养的摄取息息相关。评估消化系统需要以整体观点来评估患者，了解正常的肠胃系功能有利于教学。