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assessment exam 2 > Abdomen > Flashcards

Abdomen Flashcards

1
Q

Abdomen assessment

A 
stand on the patients right side
order of assessment: 
Inspection
auscultation
percussion
palpation
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2
Q

inspection

A 
Scars
Striae
Dilated veins
Rashes/lesions
Masses
Umbilicus
Contour
Symmetry
Peristalsis
Pulsations
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3
Q

Scars/Striae note

A

size, color, location

striae may be silvery color, stretch marks due to pregnancy, rapid weight gain or large weight loss

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4
Q

dilated veins

A

prominent, dilated veins occur with portal hypertension, cirrhosis, ascites, vena cava obstruction, and malnutrition

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5
Q

Rashes, lesions, masses

A

link to skin assessment
ABCDE
asymmetry, border, color, diameter, elevation and enlargement

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6
Q

umbilicus

A

note contour, location, and any signs of inflammation or hernia. An umbilical hernia protrudes through the umbilicus

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7
Q

Contour of abdomen

A

flat: appropriate weight and muscle tone
scaphoid: sunken (dehydration)
rounded: slightly obese, early pregnancy
protuberant: pregnancy, distension, obesity, tumors, ascites

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8
Q

Peristalsis

A

eye level to assess
may need to observe for several mintues
may be visible in thin individuals

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9
Q

Pulsations

A

aortic pulsation may be visible in the epigastric area

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10
Q

Auscultation

A

Warm the diaphragm

Begin in RLQ, then to RUQ, LUQ, LLQ

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11
Q

Bowel Sounds

A 
Normal: 5-30 per minute
Hypoactive: less than 5/minute
Hyperactive: more than 30/minutes
borborygmus: stomach growling 
Absent sounds: must listen for 5 minutes; result of decreased intestinal motility, paralytic ileus, late bowel obstruction, peritonitis, appendicitis
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12
Q

Venous Hum

A

continuous medium pitched sound auscultated in the epigastric and umbilical area. may indicate hepatic cirrohosis

very rare
listen with bell

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13
Q

Friction rub

A

rough grating sound
may indicated infection, inflammation, and malignancy

listen with diaphragm

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14
Q

percuss

A

purpose is to detect fluid, gaseous distension, and masses

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15
Q

tympany

A

Lightly percuss in all four quadrants
Move clockwise
Air in the intestines rises to the surface when supine

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16
Q

Dullness

A

Distended bladder
Adipose tissue
Fluid
Mass

17
Q

Hyperresonance

A

Gaseous distention

18
Q

liver span

A

percuss down along the right midclavicular line beginning at the nipple area, moving from lung resonance to liver dullness. mark with china pin

19
Q

liver span cont

A

percuss up along the right midclavicular line from the level of the umbilicus to liver dullness. mark with pin

measure with tape should be 6-12 inches in the adult. The liver width is greater in men and tall individuals

20
Q

percuss spleen

A

9th or 10th mid axillary line and percuss, shoudl be tympanic

dull sound could be mono, trauma, or infection

21
Q

percuss stomach

A

gastric air bubble, left side of patient 6th or 7th rib

should be tympanic

22
Q

palpation

A

begin with light palpation
start in RLQ, RUQ, LUQ, LLQ
muscular resistance- muscle tone
abdominal tenderness- stiffening with pain

23
Q

deep palpation

A

used to distinguish inferior organs or elicit deep pain

24
Q

deep masses

A

note size, location, mobility, contour, consistency(soft, firm or hard), tenderness

25
Q

tender areas

A

palpate last

26
Q

aorta

A

press deep into the upper abdomen slightly to the left of the midline. identify the aortic pulsation
Normally 2.5 cm – 4 cm in the adult
abnormal finding: widened w/ aneurysm

27
Q

upper abdominal reflexes

A

stroke the abdomen toward the umbilicus with the handle of the reflex hammer
should move toward the stimulus

28
Q

lower abdominal

A

stroke the abdomen below the umbilical area but towards the midline
umbilicus should deviate towards the stimulus

29
Q

Absent reflex

A

could indicate a pyramidal tract lesion

assessment exam 2 (5 decks)

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