Obtaining GI Health History/Why is the GI system Important?
Every encounter with a patient will need to have some degree of obtaining a health history. Health histories are used to assess the patient’s current health state, evaluate a disease process, and plan medical and nursing care (Morrissey, 1994). A detailed health history would include multiple systems of the body, however, we will be focusing on the gastrointestinal (GI) system.
In order to obtain an accurate health history regarding the GI system, appropriate questions need to be asked with terms the patient will understand. Then they will be able to provide the best and most accurate answer possible. When asking the patient questions, listen to the patient’s verbal responses, observe the patients body language and nonverbal responses, inquire about the patient’s perception of their health status, and let the patient voice his or her fears or concerns about their health or signs and symptoms they may be having. If the patient is having difficulty voicing their concerns, have them complete a questionnaire or write down questions they wish to have answered ( Morrissey, 1994).
Common GI problems or complaints include pain, heartburn, nausea and vomiting, and altered bowel habits. If the patient has any of these complaints during a health history assessment, you want to make sure you ask the patient the location, quality, onset, duration, frequency, and severity of each symptom (Lippincott and Wilkins, 2010).
Questions to ask
Be sure to ask about past medical history, include questions such as:
“Do have an ulcer?”
“…liver, pancreas, or gallbladder disease?”
“… inflammatory bowl?”
“…hiatal hernia?”
“…irritable bowl syndrome?”
“…diverticulitis?”
“…gastroesophageal reflux disease?”
“…cancer?”
“…fluctuations in weight?”
Also, be sure to ask about past abdominal surgeries or trauma (Lippincott and Wilkins, 2010).
When obtaining the patients current health history, ask the patient if they are taking any medications, allergies to medications or foods, changes in appetite or diet, difficulty chewing or swallowing, and changes in bowel habit such as constipation, diarrhea, rectal bleeding, or dark stools. Some medications such as anti-inflammatory medications, aspirin, antibiotics, and opioids can cause nausea, vomiting, and other GI symptoms. Patient’s that use laxatives over an extended period of time may start to develop constipation. Inquire about the patients home environment, such as if they are exposed to any GI symptoms in the home, food and exercise habits, oral hygiene, recent life changes and stress levels, and alcohol, caffeine, and tobacco use (Lippincott and Wilkins, 2010) ( Jarvis, 2012).
Another part of the health history that you want to be sure to ask is family history. Ask the patient if anyone in their family has had any type of GI disorder such as ulcerative colitis, colorectal or gastric cancer, peptic ulcers, alcoholism, Crohn’s disease, or celiac disease.
Enjoy this entertaining youtube Video to help you better understand our GI system– Why Digestion is important?
References:
Jarvis, Carolyn. Physical Examination & Health Assessment. St. Louis, MO: Elsevier/Saunders, 2012.
Lippincott Williams, Wilkins, and Ovid Technologies, I. (2010). Assessment: An Incredibly easy! Pocketguide. Philadelphia: Wolters Kluwer Health/ Lippincott Williams and Wilkins.
Morrissey, J. (1994). Obtaining a “Reasonably Accurate” Health History. Plastic Surgical Nursing: Officical Journal of the American Society of Plastic and Reconstructive Surgical Nurses, 14 (1), 27.