Abdominal pt. 2 Flashcards
When performing deep palpations of the abdomen,
how deep do you push?
what are you noting?
5-8 cm (2-3 inch)
Noting size and location of organs.
What is bimanual technique for palpation?
When is it used?
Placing two hands on top of each other; pushing with top hand.
Used for large/obese abdomen
What part of the abdomen is normally tender (only location that is normal)?
Sigmoid colon
What extra subjective data should you collect for:
- Children
- Adolescents/tween
- Aging adults
- Children= Risk for childhood obesity
- Adolescents= eating disorders
- Aging adults= Nutritional deficit
What are the main changes to the GI system of the aging adult?
- Constipation
- Decreased gastric secretion
- Decreased liver drug metabolism
What are normal changes to the abdomen for the aging adult?
Less abdominal tone (easy palpation)
Intestinal obstruction results in:
Vomiting
Hyperactive bowel sounds (early); Hypoactive bowel sounds (late)
Distended abdomen
What are factors that influence bowel elimination?
Age: slow with age
Fiber and fluid (bulk)
Physical activity (increases)
How should you position a patient to enhance defecation?
Raise head 30-45 degrees
How do these factors affect bowel elimination:
- Surgery/anesthesia
- Medication (opiod/antibiotic)
Surgery/anesthesia= Stop peristalsis
Opiods= slow bowel movement
Antibiotics= destroy normal flora; diarrhea
During a nursing assessement, what information should you collect on bowel elimination?
- Usual elimination pattern
- Description of stool
- Normal routine (caffeine, laxatives…)
- diet
When performing a physical assessment, what unusual info should be noted:
- Mouth
- Abdomen
- Rectum
Mouth= Sores
Abdomen= Surgeries, observable peristalsis, shape/symmetry
Rectum= hemmorhoids/lesions
Observable peristalsis usually indicates:
Intestinal obstruction
This poop indicates:
Constipation
This poop indicates:
Normal
This poop indicates:
- Lacking fiber
- Diarrhea
When creating a nursing diagnosis, what is the format?
(Diagnosis) “related to” (1-3 factors) “evidenced by” (evidence).
Constipation related to decrease in activity evidenced by patient statement, “I have not pooped in 7 days.”
After creating a nursing diagnosis, what should the nurse do next?
Create a measurable goal
- Realistic
- clear
“patient will increase activity to have bowel movement withing 48 hours”
What healthy bowel interventions should be taught to patient?
When is the best time to explain?
Instruct during patient’s mealtime
- Performing regular bowel routines
- Performing regular exercise
- Proper diet/fluid intake
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