Assessing Abdomen Flashcards
a condition in which fluid collects in spaces within your abdomen
Ascites
Abdominal Girth
Normal Finding: 80 cm
inserts two fingers into the vagina and then places pressure with the other hand to the lower part of the belly.
Bimanual Technique
Three layers of muscles
External abdominal oblique - outermost layer
Internal Abdominal Oblique - middle layer
Transverse Abdominis - innermost layer
Vertical muscle of the abdominal wall
Rectus abdominis
Oponeuroses at the midline of the abdomen forms a white line
Linea alba
The largest solid organ in the body
(T12 to L3 vertebrae)
Liver (RUQ and extended to the MCL)
Functions of Liver
-glucose storage
-formation of blood plasma protein and clotting factors
-urea synthesis
-destruction of red blood cells
-storage of iron and vitamins
-detoxification
-filtration and elimination of metabolic waste products
- blood pressure control and maintenance of water, salt, and electrolytes balances
Located behind the stomach deep in the upper stomach
Functions: endocrine gland and accessory organ of digestion
RUQ to the LUQ
Pancreas
Approximately 7cm wide and located above the left kidney just below the diaphram at the level of the ninth, and elevent ribs
Functions: filter the blood of cellular debris, to digest microorganisms and to return the breakdown products to the liver
Spleen
It is a distensible, flask-like organ located in the LUQ just below the diaphram and between the lever and spleen
Abdominal cavity
Store churn, and digest food
Stomach
A muscular sac approximately 10 cm long,
Function: concentrate and store the bile needed to digest fat
Gallbladder
Longest portion of the digestive tract ( 7.0m long)
Function: digestion and absorption of nutrients
Small intestine
Three major sections of color or large intestine
Ascending: right side of the abdomen
Transverse: across upper abdomen
Decending: left side of the abdomen
Toward the the midline
Sigmoid colon
Secrete large amount of alkaline mucus to lubricate the intestine and nuetralize acids formed by the intestinal bacteria
Temporary receptacle for urine, palpated in the abdomen above the symphysis pubis
Urinary bladder
Character
Onset
Location
Duration
Sevirity
Pattern
Associated factors
cOLDSPA
Occurs when spicific digestive organs or structures are afected by chemical or mechanical
Abdominal pain
Often described as heartburn
Ingestion (pyrosis)
Reflect gastric dysfunction and is also associated with many digestive disorders and diseases
Nausea
Anorexia
Loss of appetite
Older adult clients may experience a decline in appetite from various factors such as altered metabolism, decrease taste sensation, decrease d mobilityand possibly depression. If appetite declines, the client’s risk for nutritional imbalance incrases
Decrese in the frequency of bowel movement
Constipation
Frequency of bowel movements producing unformed or liquid stools
Diarrhea
Older adult client are especially at risk for potential complication with diarrhea- such as fluid volume deficit, dehydration, and electrolyte and acid base imbalances - because they have higher fat-to-lean muscle ratio
Older adult client are prone to UTIs because the activity of protective bacteria in the urinary tract decline with age
Occurs when hollow abdominal organ- become disteneded or contract focefully
Visceral pain
Occurs when the parietal peritoneum becomes inflamed
Parietal pain
Occurs at distant sites that are innervated at approximately the same level as the distrupted abdominal organ
Reffered pain
Epigastric pain
Stomach, duodenum, pancreas, gall bladder, billary tree, and lever
Appendex pain
Periumbilical area to RLQ
Suprapubic pain
Rectum, colon, bladder or prostate
Periumbilical pain
Small bowel, appendix, proximal colon
Auscultate after you inspect so as not alter the client’ pattern of bowel sound. Percussion then palpation follow ascultation
Sequence for Assessment of the abdomen
Abdominal assessment position is supine with arm folded across the chest or resting by the sides
Raising arms above the head or folding them behind the head will tense the abdominal muscle
A flat pillow may be placed under the client’s head for comfort. Slightly flex the client’s legs by placing a pillow or rolled blanket under the client’s knees to help relax the abdominal muscles
Instruct client to breath through the mounth and to take slow, deep breath, this promotes relaxation
Inspection- abdominal skin, umbilicus, aortic pulsation and peristaltic waves
Auscultation- bowel sound
Light palpation- superficial bulges ir pulsation
Percussion & deep palpation- abdomen and abdominal organ
Purple discoloration (Grey Tuner Sign)
Indicates bleeding within the abdominal wall, prossibly from trauma to the kidneys, pancreas, or duodenum or from pancreatis
Pale, taut skin may be seen with ascites
Ascite- significant abdominal swelling indicating fluid accumulation in the abdominal cavity
Redness may indicate inflammation
Note the vascularity of the abdominal skin
Normal: scattered fine veins
Abnormal: dilated veins may be seen cirrhosisnof of the liver, obstruction of the inferior vena cava, portal hypertention, or ascites
Spider angioma may be seen with liver disease or portal hypertention
Note any striae (stretch mark)
Normal: pink or bluish in color; old striae are silvery, white, linear, and uneven stretch marks from past pregnancies or weight gain
Abnormal: dark bluish pink striae are associated with cushing syndrome
Inspect scars
Normal: pale smooth, minimally raised old scars may be seen
Abnormal: nonhealing wound, redness, inflammation
Dilated superficial capillaries without a pattern may be seen in older clients. They are more visible in sunlight
Keloids (excess scar tissue) result from trauma or surgery and are more common in african American and Asian
Assessment for lession and rashes
Normal: abdomen is free of lesions or rashes
Abnormal: changes in moles including size, color and border symmetry. Bleeding moles or petechiae reddish or purpule lesion
Inspect the umbilicus
Normal: umbilical skin tones are similar to surrounding abdominal skin tones even pinkish
Abnormal: cullen’s sign - bluish or purple discoloration arround the umbilicus (periumbilical ecchymosis) indicates intra-abdominal bleeding
Grey turner sign - bluish of purplish discoloration on the abdominal flaks.
Purple discoloration at the flanks indicates bleeding within the abdominal wall, possibly from trauma to the kidneys, pancreas, or duodenum or from pancreatitis.
Grey-Turner sign
Instruct the client to breathe through the mouth and to take slow, deep breaths. This promotes relaxation.
inspection, auscultation, percussion, and palpation
• Abdominal edema, or swelling, signifying ascites
• Abdominal masses, signifying abnormal growths or constipation
• Unusual pulsations such as those seen with an aneurysm of the abdominal aorta
• Pain associated with appendicitis.
Observe the coloration of the skin.
Normal Findings:
-Abdominal skin may be paler
Abnormal Findings:
-Purple discoloration at the flanks
-yellow hue of jaundice may be more apparent on the abdomen.
-Redness may indicate inflammation.
-Bruises or areas of local discoloration
Note the vascularity of the abdominal skin.
Normal:
-Scattered fine veins may be visible
Abnormal :
-Dilated veins may be seen with cirrhosis of the liver, obstruction of the inferior vena cava, portal hypertension, or ascites.
