Abdominal assessment and bowel elimination Flashcards
assessment of abdomen
look and listen first!
common findings of abdominal inspection
abdominal distention, fat, flatus, fluid, fetus, fetces, fibroid.
Scaphoid (concave) abdomen: malnourishment
Abdominal inspection continued.
Localized enlargements; hernias (bulge), tumor, cyst, bowl obstruction.
Visible pulsations: may be normal in epigastric area in some individuals; marked pulsation may indicate AAA (abdominal Aortic anyeurism)
Abdominal skin
Normal: Homogeneous color is normal with smooth texture.
-Observe for color changes,
lesions and rashes
Scars r/t trauma or surgeries
Straie (stretch marks) related to pregnancies, rapid growth, cushings, obesity
Cullens sign
perimbilical bleeding and turners sign (flank bleeding) associated with hemorrhagic pancreatitis, trauma, leaking AAA, coagulopathy, or ruptured ectopic pregnancy
organs in each region
RUQ
- right lobe of the liver
- gallbladder
- pylons
- duodenum
- head of pancreas
- hepatic flexure of the colon
LUQ
- left lobe of the liver
- spleen
- stomach
- body and tail of the pancreas
- splenic flexure of the colon
- portions of the transverse and descending colon
RLQ-
- cecum and appendix
- portion of the ascending colon
LLQ
- sigmoid colon
- portion of the descending colon
Auscultation Bowel sounds
- note character and frequency
- bowel sounds: movement of air and fluid through the small intestine
- depending on the time elapsed since eating, a wide range of normal sounds can occur
- bowel sounds are high pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5 to 30 times per minute
- do not bother to count them. Judge if they are normal, hypoactive or hyperactive
Auscultation bowel sounds
what is hyperactive sounds?
- loud, high-pitched, rushing, tinkling sounds signal increased motility
- one type is fairly common; the hyperperistalsis (increased motility) when you feel your “stomach growling,” termed borborygmus (BOR-boh-RIG-mus); loud, easily audible.
Auscultation bowel sounds
what is hypoactive or absent sounds?
- decreased motility associated with abdominal surgery, ileus, or with inflammation of the peritoneum
- a “silent” abdomen is uncommon; you must listen for 5 minutes before deciding bowl sounds are completely absent.
Auscultation bowel sounds
What are mixed abdominal sounds?
-varied sounds based on quadrant and what is happening. can by hyperactive ABOVE a mass/impaction and be absent below the blockage/stoppage.
Auscultation: Vascular sounds
Abnormal findings.
- listen with the bell
- note presence of vascular sounds or bruits w/ stenosis or occlusion of arteries
- use firm pressure, check over; aorta, renal arteries, iliac and femoral arteries, especially in people with HTN.
- usually, no such sounds is present
- note location, pitch, timing of a vascular sounds.
description and causes of borborygmi?
-hyperactive bowel sounds; loud and prolonged
causes; hunger
description and causes of abominal sounds
bowel sounds?
- high pitched, tinkling sounds
- intestinal air/ fluid under pressure; characteristic of early intestinal obstruction
description and causes of abominal sounds
bowel sounds?
- high pitched, tinkling sounds
- intestinal air/ fluid under pressure; characteristic of early intestinal obstruction
description and causes of abdominal sounds
decreased bowel sounds ?
- hypoactive bowl sounds; infrequent, abnormally faint
- possible peritonitis or ileus
description and causes of abominal sounds ?
friction rubs
- high pitched sounds over liver/ spleen (RUQ/LUQ), synchronous with respiration
- pathologic conditions (e.g tumors, infection) that cause inflammation of organs peritoneal covering
description and causes of abominal sounds
Bruits ?
- audible swishing sounds over aorta, iliac, renal and femoral arteries
- abnormality of blood flow (requires additional evaluation to determine specific disorder)
description and causes of abominal sounds
Venous hum?
- low-pitched, continuous sound
- increased collateral circulation between portal and systemic venous systems.
Palpation
- identifies areas of tenderness, distension and masses
- empty bladder
- light palpation gives a generalized idea before going deeper
- only proceed deeper when warranted and never do deep/firm palpation on a mass
- use a systemactic approach for each quadrant
- observe for guarding, grimacing, or other signs of discomfort.
- rebound tenderness, press onto the involved area and let go. Pain upon rebound indicates peritoneal tenderness common with appendicitis or peritoneal injury.
- do not palpate a pulsating abdominal mass. This might indicate an abdominal aortic aneurysm. this is why we observe/inspect FIRST
abdominal pain: broad categories.
- imflammatory (e.g appendicitis)
- mechanical (e.g bowel obstruction)
- neoplastic (e.g tumor pressing on a nerve)
- vascular (e.g clot, aneurysm)
- congenital (e.g hernia)
- traumatic (e.g blunt trauma)
Abdominal pain can refer to unusual places
-Location of the pain may not be directly over or even near the sire of the organ.
referred pain
- referred pain happens when nerve fibers from regions of high sensory input (such as the skin) and nerve fibers from regions of normally low sensory input (such has the internal organs) happen to converge on the same levels of the spinal cord.
- the best known ex. is pain experienced during a heart attack. Nerves from damaged heart tissue convery pain signals to signals to spinal cord levels T1-T4 on the left side, which happen to be the same levels that receive sensation from the left side of the chest and part of the left arm.
Some causes of acute abdominal pain
-abdominal aortic aneurysm
- usually asymptomatic, but may causes back and abdominal pain
- Pulsatile mass may be palpable
Some causes of acute abdominal pain
appendicitis?
- abdominal pain over umbilicus, moving to the right lower quadrant
- often associated with fever
- the clinical exam may show rebound tenderness and positive obturator psosa, and rovsing signs
- complete blood cell count with show an increase in WBC with a shift to the left and increased neutrophils.
Some causes of acute abdominal pain
Cholecystitis?
- pain in the right upper quadrant (toward the eoigastruc area) that may radiate to the shoulder or back
- nausea and vomiting may occur
- biliary colic (pain that increases over 2 to 3 min us sustained for 20 min or more
- positive murphy sign
Some causes of acute abdominal pain
Constipation
- possible colicky to shapr pain that can mimic appendicitis
- the patient may have diffuse tenderness on palpation as well as palpable stool
Some causes of acute abdominal pain
Diverticulitis
- left lower quadrant pain, often worse after eating and improved after defecation
- possible fever
- possible diarrhea or constipation
- abdomen may be distended and tympanic and tender to palpation over the left lower quadrant.
Some causes of acute abdominal pain
-Lleus or bowl obstruction
- diffuse pain that comes in cramping waves lasting 5 to 15 min
- nausea, followed by vomiting when the bowel obstructs
- stool may be passed distal to the obstruction and may also involve diarrhea
- abdomen may be distended with high pitched bowel sounds
- diffuse tenderness and guarding
Some causes of acute abdominal pain
Pancreatitis
- pain in the RUQ to epigastric area, possible radiating to the back; can be associated with nausea and vomiting, as well as fever
- possible ileus
- in severe cases, shock, jaundice, and pleural effusion are present
- rare signs include grey turner and cullen signs
Some causes of acute abdominal pain
Peptic ulcer disease
- Usually epigastric pain 1 to 3 hours after meals and often associated with nighttime awakenings
- sudden and severe pain with radiation to the right shoulder, along with peritoneal signs; may indicate perforation
- hematemesis or melena suggests hemorrhage
Some causes of acute abdominal pain
Peritonitis
- acute diffuse abdominal pain that may be associated with fever, nausea, and vomiting
- pain increases with any motion
- abdominal distension and rigidity
- rebound tenderness is present but in appendicitis, its diffuse rather than localized
- guarding may be present
- possible signs and symptoms of shock
Mcburneys point
- draw a line between the right anterior superior iliac spine and the umbilics.
- location the junction of the lateral and middle third of the line
- typically this area is of greatest discomfort in acute appendicitis.
Dysphagia vs Dysphasia
-DysphaGIa is defined as difficulty swallowing any liquid (including saliva) or solid material
DysphaSia is defined as Speech disorders in which there is impairment of the power of expression by speech, writing, or signs or impairment of the power of comprehension of spoken or written language
Remember the G=GI and the S=speech
Bowl elimination
Significant alterations
- constipation/impaction
- diarrhea
- flatulence
- blood in stook
- diseases of GI tract (e.g irritable bowl syndrome; diverticulitis; colon CA)
- fecal incontinence
- hemorrhoids
the most common signs and symptoms of abdominal disorders
- pain
- nausea/vomiting
- change in bowl movement
- rectal bleeding
- abdominal distention
ask about change in appetite, change in weight, food intolerance, dysphagia, current medications
Oldcart review of GI problem
Onset: eg. sudden, gradual
Location: eg quadrants, superficial, deep, change over time
Duration: e.g intermittent, chronic, acute
Aggravating: e.g food, no food, meds ,rest
relieving: e.g food, no food, meds, rest
Timing: e.g relationship to internal or external stressors/bodily functions (menses, time of day, medications)
Severity: e.g impact of functionality, ADLs; if pain -rating on scale.
Interventions
- health promotion: good diet, exercise and screening
- fiber 20-30 g/day
- fluids 2,000ml/day unless contraindicated
- promote nornal defecation through position
- dont delay defecation
- pharmacological interventions such as..
- cathartics/lacatives
- anti-diarrheals
- enemas
- digital stool removal
- Nasogastric tube (through nose into GI tract)
foodbrone diseases are a primary cause of diarrhea; account for approximately 76 million illnesses, 325,000 hospitalizations and 5,000 deaths each year in the USA; more than one billion dollars in direct medical costs
Altered elimination
Diarrhea
- diarrhea reflects increased water content of the stool, whether due to impaired water absorption and or active water secretion by the bowel
- severe infectious diarrhea: number of stools may reach 20 or more per day with defecation occurring every 20 to 30 mintues , the total daily volume of stool may exceed two liters with resultant electrolyte imbalances especially volume depletion and hypokalemia.
Altered elimination
Constipation
-prevalence: patients greater than 65 are greater risk
Etiology
- improper diet (lack of fiber)
- lack of exercise
- medications (opiodis, anti cholingergics, iron, calcium channel blockers, diurectics)
- disease states (e.g diabetic gastroparesis; IBS)
- emotional stress
- pregnancy
- surgery
- spinal cord injury
Alter elimination
Constipation
Common symptoms
- decreased frequency of stools
- hard, dry, formed stools
- straining while stooling; painful defecations
- reports of rectal fullness or pressure
- reports of incomplete bowl evacuations
- abdominal pain, cramps, or distensions
- anorexia, nausea
- headchae
types of laxatives
Bulk forming
action: increased the fluid, gaseous or solid bulk in the intestines
teaching info: may take 12 or more hours to act, sufficient fluid must be taken. Safe for long-term use, slow -acting may take several days
Types of Laxatives
Emollient/ stool softener
actions: softens and delays the drying of the feces; permits fat and water to penetrate feces
Types of laxatives
Stimulant/irritant (Dulcolax, senna)
actions: irritates the intestinal mucosa or stimulates nerve endings in the wall of the intestine, causing rapid propulsion of the contents
patient teaching: acts more quicly than bulk, forming agents
Types of laxatives
Stimulant/irritant (Dulcolax, senna)
actions: irritates the intestinal mucosa or stimulates nerve endings in the wall of the intestine, causing rapid propulsion of the contents
patient teaching: acts more quicly than bulk, forming agents
Types of laxatives
Lubricant (mineral oil
Lubricates the feces in the colon
Patient teaching: prolonged use inhibits the absorption of some fat-soluble vitamins.
Types of laxatives
Saline/ Osmotic
(epsom salts, magnesium citrate)
action: draws water into the intestine by osmosis, distends bowl and stimulates peristalsis
teaching : can cause fluid and electrolyte imbalance, particularly in older people and children with cardiac and renal disease. should not be used by older clients
prolonged use inhibits the absorption of some fat-soulble vitamins.
Types of Laxatives
New eletrolyte- free (miralax)
patient teaching: a new laxative that is helpful in the treatment of constipation in children. it is a powder that is tasteless when mixed in a flavored liquid such as juice. It is a prescription drug and cost more than OTC laxatives.
Valsalva Maneuver
-straining to have a bowel movement can be dangerous for patients with coronary artery disease, HTN, cerebral edema, heart failure
patient inspires deeply and holds breathe while contracting abdominal muscles and bearing down, intra-abdominal and intra thoracic pressure, venous return to heart, transient bradycardia, BP, CO
paitent relaces, intra abdominal and intra thoracic pressure sudden flow of blood to heart tachycardia, BP
can be fatal for patient unable to compensate for sudden hemodynamic changes
may also cause dysrhythmias
Flatulence
- gas (flatus) in lumen intestines
- product of bacterial activity (methane, hydrogen sulfide, etc)
- average: individual produces 1/2 liter of gas/day; more depending on diet bacterial interaction
- if isnt passed, may cuase distension and severe pain (like shrek says, better out than in)
- post op patients; passing gas is a goof thing
Hemorrhoids
- prolapsed varricose veins of the rectum
- increased venous pressure r/t constipation; straining, pregnacy weight lifiting
- result in bleeding (bright red), pain, itching
treatment approaches
- avoid constipation
- warm sitz bath
- cortisone cream/ suppository
- sclerotherapy
- Hemorrhoidectomy
Ostomies/diversions
reasons for ostomies/ bowel diversion
- cancer
- tramua
- bowl disease (crohns)
- Blockage
- Diverticulitis
Ostomies
Location determines stool consistency due to the varying time for GI contents to digest and absorb H20
can be permanent or temporary, depending on underlying reason for ostomy
Stoma: intestinal opening
Bowel Diversions
Location of ostomies
Duodenum: small intestine nearest stomach
Jejunum- middle section of small intestine between duodenum and ileum
lleum- end of the small intestine
colon
bowel diversions
changes fecal consistency based on processes that normally occur before/after location
large intestine reabsorbs water
the more of large intestine removed the less water reabsorbed the softer the feces.
Loop colostomy: a loop of colon is pulled out through a cut in your tummy. The loop is opened up and stitched to your skin to form an opening called a stoma. The stoma has 2 openings that are close together. One is connected to the functioning part of your bowel, where waste leaves your body after the operation.
GUAIAC FECAL OCCULT BLOOD TEST
-Detects GI bleeding (most commonly from colorectal
CA); routine screening for age > 50 yrs.
Relatively insensitive (< 30% carcinomas bleed sufficiently to be detected by this test), but if done in concert with colonoscopy/sigmoidoscopy mortality
- normal= negative
- Collection: diet free of exogenous peroxidases (fish, horseradish, turnips), no vitamin C, no medicines that irritate GI tract (e.g NSAIDS)
- patient collects 2-3 consecutive stool specimens; uses a wooden stick to place sample on assay card (rectal exam sample may also be used)
GUAIAC FECAL OCCULT BLOOD TEST
-Abnormal= positive
-Colon or rectal polyps or cancer, hemorrhoids, anal
fissures, esophageal or gastric cancer, peptic ulcers,
ulcerative colitis, Crohn’s disease, GERD, esophageal
varices
False positive
-Recent dental procedure with bleeding gums, eating
red meat within 3 days of test, fish, turnips,
horseradish, high doses of Vitamin C, NSAIDs
Geriatric GI changes
decrease in salivary secretion
tooth enamel and dentin erode contributing to tooth loss and gum erosin
greater incidence of hiatal hernia and gastroesophageal reflux
increased gastric emptying time
liver decreases in weight and size and liver blood flow decreases
increased incidence of gallstones
decrease production of intrinsic factor contributing to development of pernicious anmeia
constipation becomes more common but probably more a result of lifestyle factor than physiological change
absorption of proteins, fats, minerals and some vitamins occurs more slowly
some delay in gastric mobility and emptying
weakening of intestinal walls with greater incidence of diverticulitis
decreased acid production contributing to achlorhydria
decreased esophageal mobility
taste buds decrease in number.
