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Nursing Funds > Abdomen > Flashcards

Abdomen Flashcards

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1
Q

how many quadrants do you divide the abdomen into?

A

four

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2
Q

Begin with ____ and follow with auscultation

A

inspection

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3
Q

Skin, umbilicus, contour and symmetry, enlarged organs or masses, movements or pulsations

A

inspect these areas

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4
Q

what are you auscultating for?

A

bruits
peristalsis
bororygmi

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5
Q

what are you going to obtain in their health history?

A

appetite
weight gain or loss
dysphagia
intolerance to certain foods
any abdominal pain
n/v
bowel movements
past abdominal problems

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6
Q

antiemetics need to be given ____ minutes before eating or drinking for a patient who is nauseous ?

A

30 - 40 minutes

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7
Q

-How do you get your groceries?
-Prepare your meals?
-Do you have any trouble swallowing?
-How often do you have bowel movements?
-How often do you take anything forconstipation? Rx / OTC/ herbs
-What meds do you take?

A

age considerations for older adults, these are questions you need to ask

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8
Q

t/f: Aging should not affect general GI function unless associated with a disease process

A

true

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9
Q

what decreases with age in the mouth?

A

salivation
sense of taste
gastric acid secretion
esophageal emptying
liver size
bacterial flora

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10
Q

what increases with age as far as GI in older adults?

A

constipation

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11
Q

Nutrition
Allergies
Medications
Cigarette/tobacco
ETOH intake
Recreational drug use
Stool characteristics
Urine characteristics
Exposure to infectious disease
Recent stressful life events
Possibility of Pregnancy

A

focused health history

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12
Q

What are the steps for assessment in proper order?

A

inspection
auscultation
percussion
palpation
other tests

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13
Q

Labs with abdominal pain?

A

UA
CBC -possible infection if elevated
LFT -liver function test
Guiac card -checks stool for blood

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14
Q

what do you want to do before palpating the bladder?

A

have them urinate

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15
Q

what position do you palpate abdomen in?

A

supine

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16
Q

what is the first thing youre going to do before palpating?

A

provide privacy

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17
Q

when should you palpate painful areas?

A

last

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18
Q

Skin color
Striae, scars, veins
Symmetry, contour
Distention or masses

A

inspection

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19
Q

Accumulation of fluid in the peritoneal cavity
Portal Hypertension
Decreased Liver Function
Spider nevi (cutaneous angiomas)
Caput medusae
Visible or distended veins

A

liver failure from alcoholism
ascites

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20
Q

what is this?

A

ascites

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21
Q

can indicate liver disease (abd/chest, sometimes back)

A

spider angioma

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22
Q
A

spider angioma

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23
Q
A
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24
Q
A
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25
Q
A

ostomy and stoma

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26
Q

which quadrants do you listen for bowel sounds in ?

A

all four

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27
Q

which direction do you go in when auscultating?

A

clockwise

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28
Q

how much do you need to listen to minimum for each quadrant?

A

at LEAST 5 SECONDS

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29
Q

: a rumbling or gurgling noise made by the movement of fluid and gas in the intestines. Sometimes audible to the naked ear.

A

BORBORYGMUS

30
Q

how long should you listen to bowel sounds in each quadrant before you document no bowel sounds heard?

A

5 minutes in each quadrant

31
Q

how many sounds are normal per minute?

A

5-30 sounds per minute

32
Q

is no bowel sounds a medical emergency/

A

yes

33
Q

Listen for at least _______ in all quadrants before documenting absent bowel sounds

A

5 minutes

34
Q

______ sounds could mean an obstruction = this can be an urgent situation

A

Hyperactive

35
Q

Determines size and shape of the liver, spleen, and kidneys
Detects fluid, gaseous distention, and masses
Gently tapping on the skin to create a vibration

A

percussion

36
Q

tympany ?

A

gas

37
Q

dullness indicates?

A

solid masses, fluid

38
Q

Performed last
Detects tenderness, distention, or masses
May be light or deep, as appropriate
Aortic pulsation

A

palpation

39
Q

detects aortic pulsation

A

palpation

40
Q

Use light pressure from the finger pads
detects painful areas and masses
watch the clients face for painful reaction
note areas of tenderness and masses
note if ripple life effects are pesent
patient guarding

A

palpation

41
Q

location of pain is not necessarily where the involved organ is, this is called?

A

referred pain

42
Q

what factors affect bowel elimination?

A

Lifestyle; Psychological Variables
Food & Fluids (milk products and cheese can cause constipation)
Activity/Muscle Tone
Pathologic conditions
Medications
Diagnostic Tests; Surgery/Anesthesia

43
Q

constipation meds?

A

laxatives/stool softeners
enemas or suppositories

44
Q

what is the biggest concern with diarrhea?

A

dehydration

45
Q

how do you help promote skin integrity with elimination?

A

don’t leave patient on bedpan for long periods of time
clean well

46
Q

what do you use the HAT for?

A

Use a toilet hat to collect urine and/or bowel movement

47
Q

Abdomen soft, rounded, and symmetric without distention; no lesions or scars, or visible peristalsis. Bowel sounds present in all 4 quadrants. No tenderness on palpation. Reports good appetite; no constipation, last BM this morning, medium/soft, no nausea or diarrhea. Voiding well and denies laxative use.

A

documentation for a normal exam

48
Q

hemoptysis

A

coughing up blood

49
Q

hematemesis

A

vomiting of blood

50
Q

tympany indicates?

A

gas

51
Q

dullness indicates?

A

solid masses, fluid

52
Q

uses light pressure from finger pads
detects painful areas and masses
watch the clients face for painful reaction
note areas of tenderness and masses
note if ripple life effects are present
patient guarding

A

palpation

53
Q

Depress about 1 cm
-Assess skin pulsations
-Always ______ palpation before deep palpation
-Clockwise fashion

A

light

54
Q

______palpation- depress skin about 5-8 cm

A

Deep

55
Q

Always assess tender areas ______
Watch pt’s expression during palpation

A

last

56
Q

location of pain is not necessarily where the involved organ is, is what?

A

referred pain

57
Q

may be felt where the organ was located in fetal development

A

referred pain

58
Q

spleen referred pain can present?

A

in the left shoulder

59
Q

kidney referred pain may present where?

A

groin pain

60
Q

separate hard lumps in feces incidates?

A

very constipated

61
Q

lumpy and sausage like

A

slightly constipated

62
Q

a sausage shape with cracks in the surface

A

normal

63
Q

soft blobs with clear cut edges

A

lacking fiber

64
Q

mushy consistency with ragged edges

liquid consistency with no solid pieces

A

inflammation

65
Q

Lifestyle; Psychological Variables
Food & Fluids
Activity/Muscle Tone
Pathologic conditions
Medications
Diagnostic Tests; Surgery/Anesthesia

A

factors affecting bowel eimination

66
Q

milk products and cheese can cause?

A

constipation

67
Q

constipation nursing interventions?

A

laxatives or stool softeners
enemas or suppositories
digital removal

68
Q

positioning, privacy, exercise, fiber supplement/nutrition program

A

prevention strategies for constipation

69
Q

Imodium
find and resolve cause
replace fluids and electrolytes
help decrease flatulence

A

nursing interventions for diarrhea

70
Q

Do not leave patient on bedpan for long periods of time
Clean well
promotes?

A

skin integrity

71
Q

Use a toilet ______ to collect urine and/or bowel movement

A

hat

72
Q

Abdomen soft, rounded, and symmetric without distention; no lesions or scars, or visible peristalsis. Bowel sounds present in all 4 quadrants. No tenderness on palpation. Reports good appetite; no constipation, last BM this morning, medium/soft, no nausea or diarrhea. Voiding well and denies laxative use.

A

documentation for a normal exam

Nursing Funds (17 decks)

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