Abdominal pt. 2

Question 1

When performing deep palpations of the abdomen,

how deep do you push?

what are you noting?

Answer 1

5-8 cm (2-3 inch)

Noting size and location of organs.

Question 2

What is bimanual technique for palpation?

When is it used?

Answer 2

Placing two hands on top of each other; pushing with top hand.

Used for large/obese abdomen

Question 3

What part of the abdomen is normally tender (only location that is normal)?

Answer 3

Sigmoid colon

Question 4

What extra subjective data should you collect for:

• Children
• Adolescents/tween
• Aging adults

Answer 4

• Children= Risk for childhood obesity
• Adolescents= eating disorders
• Aging adults= Nutritional deficit

Question 5

What are the main changes to the GI system of the aging adult?

Answer 5

• Constipation
• Decreased gastric secretion
• Decreased liver drug metabolism

Question 6

What are normal changes to the abdomen for the aging adult?

Answer 6

Less abdominal tone (easy palpation)

Question 7

Intestinal obstruction results in:

Answer 7

Vomiting

Hyperactive bowel sounds (early); Hypoactive bowel sounds (late)

Distended abdomen

Question 8

What are factors that influence bowel elimination?

Answer 8

Age: slow with age

Fiber and fluid (bulk)

Physical activity (increases)

Question 9

How should you position a patient to enhance defecation?

Answer 9

Raise head 30-45 degrees

Question 10

How do these factors affect bowel elimination:

• Surgery/anesthesia
• Medication (opiod/antibiotic)

Answer 10

Surgery/anesthesia= Stop peristalsis

Opiods= slow bowel movement

Antibiotics= destroy normal flora; diarrhea

Question 11

During a nursing assessement, what information should you collect on bowel elimination?

Answer 11

• Usual elimination pattern
• Description of stool
• Normal routine (caffeine, laxatives…)
• diet

Question 12

When performing a physical assessment, what unusual info should be noted:

• Mouth
• Abdomen
• Rectum

Answer 12

Mouth= Sores

Abdomen= Surgeries, observable peristalsis, shape/symmetry

Rectum= hemmorhoids/lesions

Question 13

Observable peristalsis usually indicates:

Answer 13

Intestinal obstruction

Question 14

This poop indicates:

Answer 14

Constipation

Question 15

This poop indicates:

Answer 15

Normal

Question 16

This poop indicates:

Answer 16

1. Lacking fiber
2. Diarrhea

Question 17

When creating a nursing diagnosis, what is the format?

Answer 17

(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.”

Question 18

After creating a nursing diagnosis, what should the nurse do next?

Answer 18

Create a measurable goal

• Realistic
• clear

“patient will increase activity to have bowel movement withing 48 hours”

Question 19

What healthy bowel interventions should be taught to patient?

When is the best time to explain?

Answer 19

Instruct during patient’s mealtime

• Performing regular bowel routines
• Performing regular exercise
• Proper diet/fluid intake
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