Abdomen Flashcards
how many quadrants do you divide the abdomen into?
four
Begin with ____ and follow with auscultation
inspection
Skin, umbilicus, contour and symmetry, enlarged organs or masses, movements or pulsations
inspect these areas
what are you auscultating for?
bruits
peristalsis
bororygmi
what are you going to obtain in their health history?
appetite
weight gain or loss
dysphagia
intolerance to certain foods
any abdominal pain
n/v
bowel movements
past abdominal problems
antiemetics need to be given ____ minutes before eating or drinking for a patient who is nauseous ?
30 - 40 minutes
-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?
age considerations for older adults, these are questions you need to ask
t/f: Aging should not affect general GI function unless associated with a disease process
true
what decreases with age in the mouth?
salivation
sense of taste
gastric acid secretion
esophageal emptying
liver size
bacterial flora
what increases with age as far as GI in older adults?
constipation
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
focused health history
What are the steps for assessment in proper order?
inspection
auscultation
percussion
palpation
other tests
Labs with abdominal pain?
UA
CBC -possible infection if elevated
LFT -liver function test
Guiac card -checks stool for blood
what do you want to do before palpating the bladder?
have them urinate
what position do you palpate abdomen in?
supine
what is the first thing youre going to do before palpating?
provide privacy
when should you palpate painful areas?
last
Skin color
Striae, scars, veins
Symmetry, contour
Distention or masses
inspection
Accumulation of fluid in the peritoneal cavity
Portal Hypertension
Decreased Liver Function
Spider nevi (cutaneous angiomas)
Caput medusae
Visible or distended veins
liver failure from alcoholism
ascites
what is this?
ascites
can indicate liver disease (abd/chest, sometimes back)
spider angioma
spider angioma
ostomy and stoma
which quadrants do you listen for bowel sounds in ?
all four
which direction do you go in when auscultating?
clockwise
how much do you need to listen to minimum for each quadrant?
at LEAST 5 SECONDS
: a rumbling or gurgling noise made by the movement of fluid and gas in the intestines. Sometimes audible to the naked ear.
BORBORYGMUS
how long should you listen to bowel sounds in each quadrant before you document no bowel sounds heard?
5 minutes in each quadrant
how many sounds are normal per minute?
5-30 sounds per minute
is no bowel sounds a medical emergency/
yes
Listen for at least _______ in all quadrants before documenting absent bowel sounds
5 minutes
______ sounds could mean an obstruction = this can be an urgent situation
Hyperactive
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
percussion
tympany ?
gas
dullness indicates?
solid masses, fluid
Performed last
Detects tenderness, distention, or masses
May be light or deep, as appropriate
Aortic pulsation
palpation
detects aortic pulsation
palpation
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
palpation
location of pain is not necessarily where the involved organ is, this is called?
referred pain
what factors affect bowel elimination?
Lifestyle; Psychological Variables
Food & Fluids (milk products and cheese can cause constipation)
Activity/Muscle Tone
Pathologic conditions
Medications
Diagnostic Tests; Surgery/Anesthesia
constipation meds?
laxatives/stool softeners
enemas or suppositories
what is the biggest concern with diarrhea?
dehydration
how do you help promote skin integrity with elimination?
don’t leave patient on bedpan for long periods of time
clean well
what do you use the HAT for?
Use a toilet hat to collect urine and/or bowel movement
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.
documentation for a normal exam
hemoptysis
coughing up blood
hematemesis
vomiting of blood
tympany indicates?
gas
dullness indicates?
solid masses, fluid
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
palpation
Depress about 1 cm
-Assess skin pulsations
-Always ______ palpation before deep palpation
-Clockwise fashion
light
______palpation- depress skin about 5-8 cm
Deep
Always assess tender areas ______
Watch pt’s expression during palpation
last
location of pain is not necessarily where the involved organ is, is what?
referred pain
may be felt where the organ was located in fetal development
referred pain
spleen referred pain can present?
in the left shoulder
kidney referred pain may present where?
groin pain
separate hard lumps in feces incidates?
very constipated
lumpy and sausage like
slightly constipated
a sausage shape with cracks in the surface
normal
soft blobs with clear cut edges
lacking fiber
mushy consistency with ragged edges
liquid consistency with no solid pieces
inflammation
Lifestyle; Psychological Variables
Food & Fluids
Activity/Muscle Tone
Pathologic conditions
Medications
Diagnostic Tests; Surgery/Anesthesia
factors affecting bowel eimination
milk products and cheese can cause?
constipation
constipation nursing interventions?
laxatives or stool softeners
enemas or suppositories
digital removal
positioning, privacy, exercise, fiber supplement/nutrition program
prevention strategies for constipation
Imodium
find and resolve cause
replace fluids and electrolytes
help decrease flatulence
nursing interventions for diarrhea
Do not leave patient on bedpan for long periods of time
Clean well
promotes?
skin integrity
Use a toilet ______ to collect urine and/or bowel movement
hat
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.
documentation for a normal exam
