Abdomen (Chapter 22) Flashcards
what is the order for abdomen assessment
inspection
auscultation
percussion
palpation
what organs fall under the solid viscera
liver
panceras
spleen
adrenal glands
kidneys
ovaries
uterus
what organs fall under the hollow viscera
stomach
gall bladder
small inestine
colon
bladder
hollow visera shape depends on
content
divide the abdomen into how many quadrants
4
what direction do you proceed when going through the quadrants
clockwise
why is the sequence of the abdomen assessment different than other systems
so you do not disrupt internal contents
the liver is in what quadrant
RUQ
the sigmoid colon is in what quadrant
LLQ
the bladder is in what quadrants
in the middle between RLQ and LLQ
what quadrant is the gallbladder in
RUQ
what quadrant is the spleen in
LUQ
what quadrant is the majority of the stomach in
LUQ
what quadrant is the appendix in
RLQ
why is one kidney lower than the other, what kidney is lower
the right kidney is lower due to the liver
what is the costovertebral angle found between
12th rib and spine
RUQ
right upper quadrant
LUQ
left upper quadrant
RLQ
right lower quadrant
LLQ
left lower quadrant
what quadrant would you start at because this is where bowel sounds first start after they have been absent
right lower quadrant
illocecal valve
dysphagia
difficulty swallowing
what is the best position to have the patient in when doing the abdominal assessment. why?
supine and flat
allows to see extension of the abdomen
what should you do if the patient claims they have areas of tenderness and pain
assess that area last
why do we assess the surgical scars, especially new ones
because there is a risk for infection
what should we do to our stethoscope before auscultation
warm it
does the older adult have decreased or increased salvia amounts
decreased
does the older adult have decreased or increased sense of taste
decreased
does the older adult have decreased or increased use of salt and sugar
increased
does the older adult have delayed or faster esophageal emptying
delayed
since the older adult has delayed esophageal emptying that increases their risk for
aspiration
does the older adult have decreased or increased gastric acid secretion
decreased
what anemia are older adults at risk for
pernicious
absorption of what mineral may be problematic
ca+
older adults have increased incidence of what
gallstones
what could cause a lack of symmetry in a persons abdomen
bowel obstruction
where would you note pulsations/movement
below xiphoid process
is seeing pulsations normal?
can be normal
in pregnant women
when would a pulsation not be good
AAA
abdmoninal aortic ansyersym
bruit is caused by
stenosis
if you have decreased hair this could be caused by
decreased nutrients
what is the correct term for obese patient contour of abdomen
protuberant
what could cause abdominal distension
bulges and masses
hernia
obesity
air or gas
ascites
feces
ascities
edema in abdominal region
ascites can be accompanied by
renal failure and use of peritoneal dialysis
what part of stethoscope do we use for the bowel sounds
diaphragm
normal bowl sounds
high pitches, gurgling, cascading, IRREGULAR, 5-30 per min
hypoactive
<5 min
hyperactive
> 30 min
how long do we listen to determine normal/hypo/hyper
no set amount of time, the amount of time for you to assess
if we have a patient with absent bowl sounds how long do we have to listen to make this determination
5 mins
why might someone have absent bowl sounds
NPO
where do you auscultate the aorta
midline under xiphoid process, above belly button
where do you auscultate the renal arteries
above belly button laterally
where do you auscultate the iliac arteries
below belly button laterally
what part of the stethoscope do we use to listen do vascular sounds
bell
what is normal when listening to vascular sounds
normal not to hear anything
what is a bruit
abnormal
caused by stenosis of an artery that results in turbulent blood flow
what pattern should you use when percussing
zigzag side ways bc that is the way the intestines flow
what should be the dominate sound produced in the abdomen
tympany
where would you hear a dull sound
over organs
where would you hear a flat sound
over bone
what are the tests used for ascites to confirm abnormal fluid
testing for fluid wave
testing for shifting dullness
would you be able to feel the enlarged liver and nodule liver with light or deep palpations
light
what enlarged organs would have to be felt with deep palpations
spleen and kidney
do you start with light or deep palpation
light palpation and then deep palpation
when enlarged liver it can extend below
the ribs
rebound tenderness is called what sign
blumbergs
rebound tenderness
peritoneal inflammation associated with appendicitis
rebound tenderness is pain when
pressure is released
inspiratory arrest is called what sign
Murphys sign
inspiratory arrest is a test for
inflamed gallballder
CVT
posterior percussion over kidneys
striae is associated with
ascites
umbilical hernia
usually intestine, belly button, have the person cough
epigastric hernia
epigastric region, felt and palpable when patient stands
incisional hernia
can be anywhere there is an incision and seen sitting and standing
rebound tenderness what organ
appendix
Murphys sign what organ
gallbladder
how might you tell if an abdomen with a rounded appearance is filled with fluid, gas, or mass
fluid wave
shifting dullness
when the patient reports that a certain spot in the abdomen is tender it is best to
A. palpate that spot last, to prevent pain from interfering with the rest of the examination
B. palpate that spot first, to avoid prolonging the patients anticipation
C. avoid that spot entirely, as other clinicians are going to palpate it after you
D. palpate in the same order as you always would, to avoid missing something because you broke your routine
A. palpate that spot last, to prevent pain from interfering with the rest of the examination
which of the following is not in the list of common causes for abdominal distension
A. flatus
B. fetus
C. fluid
D. Follicles
E. Fat
D. Follicles
which of the following answers are true (SATA)
A. listen for bowel sounds in each quadrant
B. Always auscultate before palpating as palpation may alter bowel sounds
C. Use the bell of stethoscope to auscultate for bowel sounds
D. Listen for at least 5 mins before documenting that bowl sounds are absent
A, B, D
the patient has hypoactive bowel sounds. the nurse knows that a potential cause of hypoactive bowel sounds is
A. diarrhea
B. Peritonitis
C. Laxative use
D. Gastroenteritis
B. Peritonitis
when examining a patent with good muscle wall relaxation the nurse observes abdominal pulsations between the xiphoid and umbilicus, the nurse would suspect that there are
A. pulsations of the renal arteries
B. pulsations of the inferior vena cava
C. normal abdominal aortic pulsations
D. increased peristalsis from a bowel obstruction
C. normal abdominal aortic pulsations
