Abdominal System Flashcards
Viscera
Refers to the soft internal organs
Peritoneum
Layers of tissues that line the abdominal cavity and organs
Straie
Stretch marks or indented streaks in the skin
Ascites
Abdominal fluid build-up in the spaces between the abdominal lining/region
Keloid
A type of raised scar resulting from excessive scare tissue growth
Hepatomegaly
Enlarged liver
Splenomegaly
Enlarged spleen
CVA Tenderness
Costovertebral tenderness
AAA
Abdominal Aortic Aneurysm
Peristalsis
Involuntary contraction & relaxation of muscles in the GI
Hernia
When the intestines push through a weak abdominal muscle
Anastomosis
Surgical connection of two body structures
Fistula
Abnormal openning/passage between two body areas or surfaces
Ulcer
Open Erosions
Barrett’s Esophagus
Esophageal condition where the intestinal cells migrate into the esophagus, causing bleeding
Candid (what type of microorganism, what is it caused by, and what can it cause?)
Fungal infection caused by yeast (e.g., oral thrust)
Polyps
Abnormal growth of cells that protrudes to the surface
Diverticula
small bulging pouches or sacs that form in the lining of the colon
BRBPR
Bright red blood per rectum
Hemochezia
Fresh blood
Esophageal varices
Enlarged dilated submucosal vessels
Melena
Black, tarry, sticky stool
Odynophagia
Painful swallowing
Tenesmus
A persistent, painful urger to defecate without excreting stool
Borborygmus
Gurgling, rumbling sounds from abdomen
What is solid viscera?
Consistently maintain shape (liver, kidney, spleen, pancreas uterus, ovaries)
What is a hollow viscera?
Change shape (stomach, SI, gallbladder, LI, colon, sigmoid colon, bladder)
Referred pain
Pain originating from a location that references a organ in a different location
How do patients describe visceral pain?
Dull, aching, burning, cramping, colicky, poorly defined or localized. Intermittent.
Secondary to distention of hollow organs or stretching of capsules or hollow organs.
How do patients describe parietal pain?
Localized to the source, severe, steady
Inflammation of parietal peritoneum such as appendicitis and peritonitis
How do patients describe referred pain?
Pain at distant site
What is the physical order examination for the abdomen?
Inspection, Auscultation, Percussion, Palpation
When you auscultate how do you listen, what is the order?
You listen with the diaphragm for bowel sounds.
You listen with the bell for vascular sounds.
You start in the RLQ and go clockwise
What do you hear when you percuss over the empty spaces in the abdomen?
Tympany
What is the depth of deep palpation?
5 to 6 cm deep
Cullen’s Sign
A bluish or purple discoloration around the umbilicus (periumbilical ecchymosis) indicating intra-abdominal bleeding
Turner’s Sign
Indicates bleeding within the abdominal wall, possibly from trauma (usually retroperitoneal/flank)
What do hyperactive bowel sounds, sound like?
Gurgling, high pitched, rapid peristalsis as in gastroenteritis and diarrhea, could be the beginning of a bowel obstruction
How long do you have to listen to bowel sounds?
5 minutes
Dead or absent bowel sounds
Absent motility, may indicate an emergency
What do hypoactive bowel sounds, sound like?
They are diminished usually due to an obstruction or surgery
What is a bruit
Rushing sounds through tight vessels (low pitched murmur)
What is a venous hum
Continuous roaring or whining sound heard in the epigastric area. Can be secondary to liver disease with portal vein hypertension
Where is friction rub heard and what can it indicate?
May be heard over right and left lower rib cage, liver, and spleen area. May indicate cancer.
Indirect percussion
Middle finger of non-dominant hand where you strike with two quick taps
Blunt percussion
one hand flat on surface, struck by fist of other hand looking for CVA tenderness
Direct percussion
Directly tapping body part with one or two fingers. Checking for tenderness
When is a percussion contraindicated
Suspected aortic aneurysm, appendicitis, abdominal organ transplant
Spleen dimension (cm)
7cm
Where is CVA tenderness located?
Posteriorly, approximately over the 12th rib
What can cause CVA tenderness?
Pyelonephritis, kidney stones, etc
You are performing an abdominal assessment and there is a pulsating mass at the center. How do you palpate?
YOU DO NOT! AAA
What are 6 abnormal findings of abdominal distention?
Pregnancy, Fat, Feces, Fibroids, and others, Flatus, Ascitic fluid
What are 4 abnormal findings of abdominal buldges?
Umbilical hernia, epigastric hernia, diastases recti, incisional hernia
Considerations for older adults
Older adults have a diminished sensitivity for pain, decline in appetite, increased risk for UTI/diarrhea, dilated superficial capillaries, narrowed aorta, need screening for abdominal aortic aneurysm
Client is experiencing diarrhea, upon auscultation what would expect to hear?
Hyperactive bowel sounds
Client is experiencing constipation, upon auscultation what would expect to hear?
Hypoactive bowel sounds (during surgery or obstruction)
When performing the abdominal assessment for a client, what assessment technique do you perform first?
Inspection
During deep palpation of the abdomen, a client experiences right lower quadrant rebound tenderness. What additional assessment should the nurse conduct?
Palpate Rovsing’s sign
Assess for a Psoas sign
Assess for Obturator sign
What tests assess for appendicitis?
Psoas and rebound tenderness
How do you assess for rebound tenderness?
Palpate deeply at 90 degrees into the abdomen halfway between the umbilicus and the anterior iliac crest (McBurney point).
What is Mcburney’s point?
the point on the lower right quadrant of the abdomen at which tenderness is maximal in cases of acute appendicitis
What does it mean if no rebound tenderness is present?
It suggests there is no peritoneal irritation
What indicates rebound tenderness?
The client experiences sharp, stabbing pain when the examiner releases pressure from the abdomen (Blumberg sign)
How do you assess for the obturator sign?
Ask the patient to lift their leg straight, then rotate internally and externally.
What does pain in the RLQ during the obturator sign test indicate?
Irritation of the obturator muscle, which may be due to appendicitis or a perforated appendix.
How do you test for cholecystitis?
Assess RUQ pain or tenderness by pressing your fingertips under the liver border at the right costal margin and ask the client to inhale deeply
What does it mean if there is no increase in pain during the test for cholecystitis?
It suggests that cholecystitis is not present.
What is a positive Murphy sign and what does it indicate?
Accentuated sharp pain that causes the client to hold their breath (inspiratory arrest) is a positive Murphy sign, indicating acute cholecystitis.
What is Rovsing sign and what does it indicate?
Pain in the RLQ during pressure in the LLQ is a positive Rovsing sign, indicating acute appendicitis.
What does psoas sign assess for?
Appendicitis
What are indicators of positive psoas sign?
Pain in the RLQ (psoas sign) is associated with irritation of the iliopsoas muscle due to appendicitis (an inflamed appendix).
How does a nurse assess for psoas sign?
Ask the client to lie on the left side. Hyperextend the client’s right leg
During an abdominal assessment, why is the gallbladder not typically distinguishable from the liver upon palpation?
The gallbladder is deep to the liver and blends with its structure.
The nurse suspects an abdominal aortic aneurysm when what is assessed?
Abdominal bruit
The client may exhibit decreased femoral pulses, hypotension and cool extremities.
An older client presents with symptoms of pain upon urination. The nurse recognizes that older adults are at increased risk for urinary tract infections because…
Older adult clients are prone to urinary tract infections because the activity of protective bacteria in the urinary tract declines with age.
The nurse is palpating in the right upper abdominal quadrant and feels and enlarged area. The nurse recognizes that they are most likely feeling what organ?
Liver
Tenderness or sharp pain elicited over the costovertebral angle occurs with what conditions?
renal calculi, hydronephrosis, or a kidney infection
Tenderness over the liver is associated with…
hepatitis and cholecystitis.
What characteristic of pain is commonly associated with a duodenal ulcer?
Awakens the patient at night
The nurse is auscultating the abdomen and notes a swishing sound in the abdominal area. The nurse would document this sounds as a what?
Bruit
The nurse must listen for at least ___ minutes (per quadrant) before determining that no bowel sounds are present and that the bowels are silent.
5 minutes
What age group experiences a decline in appetite, although enzyme production does not significantly decrease?
Older Adults
T/F the liver decreases in size with age
True
A client’s bladder is found to be distended. At which location should the nurse begin palpating?
At the umbilicus
In the left lower quadrant
At the symphysis pubis
In the right lower quadrant
At the symphysis pubis
A young adult male who comes to the emergency department complaining of abdominal pain for the past 3 days is suspected of having a ruptured appendix. What bowel sound would the nurse expect to assess in this client?
Absent bowel sound
Associated with peritonitis, which would occur with a ruptured appendix.
The nurse is evaluating a new graduate’s ability to perform a rebound tenderness test. The nurse identifies correct technique when the new graduate is observed pressing deeply at which abdominal location?
Right lower quadrant
The ideal position for measuring abdominal girth is ___
Standing, if they cannot stand then supine
The liver is what type of viscera? (solid viscera or hollow viscera)
Solid viscera
The spleen is what type of viscera? (solid viscera or hollow viscera)
Solid viscera
The stomach is what type of viscera? (solid viscera or hollow viscera)
Hollow viscera
The uterus is what type of viscera? (solid viscera or hollow viscera)
Solid viscera
The pancreas is what type of viscera? (solid viscera or hollow viscera)
Solid viscera
The Gallbladder is what type of viscera? (solid viscera or hollow viscera)
Hollow viscera
The colon is what type of viscera? (solid viscera or hollow viscera)
Hollow viscera
Do antacids inhibit or relieve peptic ulcers?
Relieve
The nurse would assess for positive Blumberg sign how?
Applying and releasing pressure to the abdomen
Rebound tenderness is also known as…
Blumberg sign
The nurse assess for kidney tenderness at what location?
Costovertebral angle
A nurse notices a bulge in the right lower quadrant of a client’s abdomen during inspection. How should the nurse further assess this finding using inspection?
A) Ask the client to raise their head off the bed.
B) Perform palpation of the area to assess the mass.
C) Ask the client to cough.
D) Perform percussion of the abdomen to assess the mass.
Asking the client to raise the head off the bed will help the nurse to determine the location of the mass. A mass within the abdominal wall is more prominent when the head is raised, whereas a mass below the abdominal wall is obscured.
A client reports the onset of pain in the left upper quadrant of the abdomen with the ingestion of alcohol. The nurse recognizes that alteration in function of which organ is most likely to be the cause of this pain?
The pancreas is most likely to be the cause of the pain in the left upper quadrant with ingestion of alcohol because chronic use causes inflammation of this organ.
Straight leg test is also known as what kind of sign?
Psoas sign
The nurse is assessing a client for acute cholecystitis. What sign would they assess for?
Murphy’s sign
Purple straie may be seen with ____ or ____.
Cushing’s syndrome or ascites.
Peristaltic waves are seen with…
Intestinal obstruction
CVA tenderness is found over what rib?
12th rib
Directly tapping the area with 1 or 2 fingers is known as what type of percussion?
Direct
How large is the liver?
6 to 12 cm
How large is the spleen?
7 cm at its widest
What palpation technique is used to detect tenderness or muscular resistance?
Light palpation
Pain upon palpation of LLQ which identified referred pain from appendix is what sign?
Rovsing sign
When can the urinary bladder be palpated?
When distended
Should the kidneys be palpated when distended?
No
Should the spleen be palpated when distended?
No
What should the nurse assess in a patient that is older than 50 years old and presents with hypertension?
Assess the width of the aorta
T/F Sensitivity to pain may diminish with aging
True
