ABDOMINAL ASSESSMENT Flashcards
What area is only exposed in the abdominal assessment?
Xiphoid Process to the Symphysis Pubis
What should you inspect in the abdominal?
inspect abdominal contour
Where should you inspect at the abdominal contour?
area bet. lower ribs and pubic bone
What is the findings of the abdominal contour?
The abdomen is flat
What should you measure and observe in the abdominal symmetry?
protrusion
bulging
lumps
abdominal girth
TRUE OR FALSE: The abdomen must be paler than general skin tone.
TRUE
What should you inspect in the abdomen?
umbilicus
Normal findings for hernia or diastasis recti
abdomen does not bulge when client raises head
A slight pulsation of the
abdominal aorta is noted in the _____
epigastrium
Peristaltic waves should (BE OR NOT BE) seen
Not seen
What side of the stethoscope is used to auscultate the bowel sounds?
diaphragm
Where should you begin auscultating the bowel sounds?
right lower quadrant and proceed clockwise
bowel sound is more active over the
Ileocecal Valve in the RLQ
What side of the stethoscope should you use when you auscultate the vascular sounds and venous hum?
Bell
Where should you listen for bruit sounds?
abdominal aorta
renal
iliac
femoral
Where should you listen for venous hum?
epigastric and umbilical areas
Where should you auscultate the friction rubs?
right and left lower rib cage
Where should you start percussing the abdomen?
right upper quadrant and end at the right lower quadrant
what tone predominates over all
four quadrants.
tympany
is heard over liver and spleen
dullness
The liver span in the midclavicular line is
6 cm
the liver span in the midsternal line is
4 cm
When performing the scratch test you should place the diaphragm of the stethoscope at the
2nd to the last intercostal space, midclavicular line
When percussing the spleen, the client’s position must be
right side-lying position with left knee flexed and right leg is straight
Where should you begin percussing for the spleen?
posterior to the left midaxillary line
The tone in the spleen should change from ____ to ____
resonance to splenic dullness
What is the vertical size and longitudinal of the spleen?
vertical size- 5 cm
longitudinal size- 6 cm
What percussion method should you use for the liver tenderness?
blunt percussion
client’s position in blunt percussion?
supine
What side of the fist should you use to strike the left hand?
ulnar side
What method should you use for the kidney tenderness?
kidney punch test
Where should you place your left hand during kidney punch test?
costovertebral angles over the 12th rib
for bimanual technique where should you place your left hand?
client’s back at the level of the 11th to 12th ribs
What palpation techniques should you use for the liver?
bimanual and hooking technique
When palpating for the spleen what is the position of the client?
right side-lying
Where should you begin palpating for the urinary bladder for distention?
symphysis pubis to the umbilicus
is a condition in which the fluid is collects in the spaces within the abdomen
ascites
What is the position of the client when you test for ascites?
lateral decubitus position
what percussion technique should you use to test for shifting dullness?
indirect percussion
Palpating for rebound tenderness you should apply ____ using both hands in the
deep pressure
right lower quadrant
refers to the pain felt in the right lower abdomen upon palpation of the left side of the abdomen
rovsing sign
means that there is more pain when pressure on the tender area is released. It occurs when the tissue that lines the abdominal cavity (the peritoneum) is irritated, inflamed, or infected.
rebound tenderness
What should you do to assess for psoas sign?
client lie on left side
hyperextend client’s leg
When you assess for the obturator sign what should you do?
flex the hip and knee
rotate internally and externally
A bulge at the umbilicus suggests an
umbilical hernia
is seen as midline protrusion from the xiphoid to the umbilicus or pubis symphysis.
diastasis recti
Marked peristaltic waves almost always indicate a pathologic process such as
pyloric stenosis
is defined as a span greater than 12 cm at the mid-clavicular line (MCL) and greater than 8 cm at the midsternal line (MSL).
hepatomegaly
is defined by an area of dullness exceeding 7 cm.
splenomegaly
may be seen with severe weight loss or cachexia related to starvation or terminal illness.
scaphoid abdomen
A bluish or purple discoloration around the umbilicus (periumbilical ecchymosis) indicates intra-abdominal bleeding
cullen’s sign
bluish of purplish discoloration on the abdominal flanks.
grey-turner’s sign
are associated with Cushing’s syndrome.
dark bluish-pink striae
may occur when a defect develops in the abdominal muscles because of a surgical incision.
incisional hernia
Vigorous, wide, exaggerated pulsations may be seen with
abdominal aortic aneurysm
A prominent, laterally pulsating mass above the umbilicus strongly suggests an
aortic aneurysm
