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Health assessment > Exam 3 GI > Flashcards

Exam 3 GI Flashcards

1
Q

Anatomic Locations of 4 Quadrants

What includes? Right upper (RUQ)

A

liver, gall bladder,head of pancreas, right kidney

hepatic flexure of colon, part of ascending and transverse colon

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2
Q

Anatomic Locations of 4 Quadrants

What includes? Left upper (LUQ)

A

Stomach, spleen, left lobe of liver, body of pancreas, left kidney

splenic flexure of colon, part of transverse and descending colon

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3
Q

Anatomic Locations of 4 Quadrants

What includes? Right lower (RLQ)

A

Cecum, appendix

Right ovary and tube, right ureter, right spermatic cord

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4
Q

Anatomic Locations of 4 Quadrants

What includes? Left lower (LLQ)

A

Part of descending colon, sigmoid colon

left ovary and tube, left spermatic cord

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5
Q

Kidneys location

A

Posterior or retroperitoneal to abdominal content
Right kidney rests 1-2 cm lower than left b/c of placement of liver

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6
Q

Lower edge of liver and right kidney ?

Small intestine ?

Pancreas?

A

Lower edge of liver and right kidney may normally be palpable.

Small intestine is located in all 4 quadrants

Pancreas soft, lobulated gland behind stomach

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7
Q

Spleen

location and function

A

Soft mass of lymphatic tissue
Post wall of abdominal cavity, below diaphragm
Fights invading germs in the blood (contains white blood cells)
Controls the level of blood cells (WBCa,RBcs,platelets)
Filters the blood and removes any old or damaged red blood cells

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8
Q

How to assist abdominal pain?

Acute upper and lower pain or discomfort

A
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9
Q

Dysphagia

A

Difficulty swallowing

Taking more time and effort to move food or liquid from your mouth to your stomach.

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10
Q

Chronic upper discomfort or pain, most reason?

A

Functional dyspepsia

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11
Q

You are completing a general physical examination on Mr. Rock, a 39-year-old man with complaints of constipation. When examining a patient with tense abdominal musculature, a helpful technique is to have the patient:

A

flex his or her knees

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12
Q

Proper Order of the Examination

A

Inspection
Auscultation
Percussion
Palpation

It is believed that percussion and or palpation can change the intestinal motility

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13
Q

Chronic lower pain

A

Ask about changes in bowel habits

(Diarrhea? constipation?)

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14
Q

What subjective dates we want to get? 10

A

Appetite
Dysphagia
Abdominal pain
Nausea and vomiting
Bowel habits
Past abdominal history
Medications
Recent stressful life events
Possibility of Pregnancy
Nutritional assessment

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15
Q

Tips for the Examination

A

Patient should have an empty bladder
Bend the patient’s legs
Be on patient Right side
Supine position w/ hands by side
Painful area examined last

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16
Q
A
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17
Q
A
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18
Q

Inspection first!

Look at the contour of the abdomen
If not FLAT, think of 7Fs

A

Fat
Fibroids
Flatus
Fluid
Fetus
Feces
Fatal Tumor

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19
Q

Inspection/Contour

What it look for?

A

Flat, Rounded or Scaphoid

Flat is common in well-muscled athletic adults
Rounded—young children—or in an adult is fat or poor muscle tone
Scaphoid—Thin adults

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20
Q

Spider Angiomas

A

Often alcoholic cirrhosis

but also pregnancy, collagen vascular disorders

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21
Q

Striae

A

Stress marks consistent with weight loss
Could be pregnancy, tumors or ascites

ascites/Excess abdominal fluid, caused most often related to liver disease

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22
Q

adhesion/癒着

A

Presence of scars not explained before could lead to history information

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23
Q

Auscultate the abdomen

A

Begin in RLQ at ileocecal valve

Ileocecal valve
Muscular sphincter that allows contents to move from the ileum of the small intestine to the cecum of the large intestine

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24
Q

“Silent abdomen” is uncommon

What we are going to do?

A

Must listen for 5 minutes before deciding bowel sounds are completely absent

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25
Q

vascular sounds

How are we gonna listen?

A

Listen all 4 quadrants
Begin in RLQ at ileocecal valve

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26
Q

Bowel sounds

Increase?
Decrease?

A

Auscultation=Bowel motility

Increased
-diarrhea or early intestinal obstruction

Decreased
-Adynamic ileus and peritonitis

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27
Q

Peritonitis?

A

Inflammation of the membrane lining the abdominal wall and covering the abdominal organs.

Usually infectious and often life-threatening.

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28
Q

Adynamic ileus

A

When food or drink does not pass through the bowel
Commonly occurs for 24 to 72 hours after abdominal surgery

29
Q

Percussion helps what?

Listen for what sounds?

A

The amount and distribution of gas in the abdomen

Tympanic
Resonance
Dullness

30
Q

What are resonance, tympani and suprapubic sounds?

A

Resonance and Tympanic sound the same
Resonance hollow sounds heard over normal lung tissue

  • *Tympani**
  • drum-like sounds heard over air filled structures
  • *Gas presence** in the stomach, small bowel and colon

Suprapubic area may sound dull if bladder is distended or uterus is enlarged in a women

31
Q

Palpation

What looking for?

A

Light palpation detect abnormal tenderness, muscular resistance

32
Q

Developmental Competence

During early childhood

A

Abdominal wall is less muscular, so organ may be easier to palpate

33
Q

Developmental Competence

Teenagers

A

Ask:
nutritional assessment
activity & exercise patterns
recent wt. loss or gain

34
Q

Developmental Competence
Pregnant Woman

A

High incidence of nausea and vomiting(r/t hormones) and
“heartburn (pyrosis)” or esophageal reflux

Decrease in gastric motility which leads to constipation
Increase venous pressure in lower pelvis may lead to hemorrhoids
Skin changes on abdomen include striae and linea nigra

35
Q

Developmental Competence

Aging Adult

A

Aging should not affect GI function!!

Decreased salivation, leading to a dry mouth and decreased sense of taste
Decreased gastric acid secretion and esophageal emptying
Decreased liver size

Increased deposit of fat on abdomen and hips
Increased report of constipation

36
Q

Common Causes of Constipation

in Older Adult

A

Decreased physical activity
Inadequate intake of water
Low fiber diet
Side effects of medications
Irritable bowel syndrome
Bowel obstruction
Hypothyroidism
Inadequate toilet facilities
Difficulty ambulating to toilet

37
Q

Focused Health History

ASK Older Adults

A

How do you get your groceries?
Prepare your meals?
Do you have any trouble swallowing?
How often do your bowels move?
How often do you take anything for constipation (OTC/ herbs)?
What meds do you take?

38
Q

Referred pain

A

location of pain is not necessarily where the involved organ is!
Pain may be felt where the organ was located in fetal development
ex: spleen= L shoulder pain/ kidney= groin pain

39
Q

Rebound Tenderness

A

Rebound Tenderness= appendicitis

Pain upon removal of pressure rather than application
of pressure to the abdomen

Pain in the RLQ when pressure is released from the LLQ

40
Q

Murphy’s Sign

Hold fingers under the liver border
Ask the pt to take a deep breath
A normal response is to complete the deep breath without pain

Positive Murphy sign
Pain occurs on inspiration
Stop in inspiration

“inspiratory arrest” = cholecystitis

A
41
Q

Obturator Test

A

lift the right leg straight up, then rotate at 90 degrees= muscle is irritated by appendicitis

Pain= acute appendicitis

42
Q

Iliopsoas Muscle Test

A

Lift the right leg straight up,
Then push over the right thigh as the person tries to hold the leg up

appendicitis pain is felt in the RLQ

43
Q

The nurse is planning to assess the abdomen of an adult male client. Before the nurse begins the assessment, the nurse should

A

ask the client to empty his bladder

44
Q

A client comes to the emergency department complaining of pain in the right lower quadrant. Rebound tenderness is present and the nurse assesses the client for referred rebound experiences. The client experiences pain the right lower quadrant. The nurse interprets this as which of the following?

A

Positive Rovsing’s sign

45
Q

The nurse is palpating in the right upper abdominal quadrant and feels and enlarged area. The nurse recognizes that she is most likely feeling what organ?

A

Liver

46
Q

The nurse is assessing a client with a bladder disorder. Where would the nurse expect the pain to be?

A

Suprapubic

47
Q

The nurse correctly identifies the gallbladder is located where?

A

RUQ

48
Q

While auscultating a client’s abdomen, the student notes sounds that are both high-pitched and rushing. The student demonstrates an understanding of abnormal bowel sounds when proposing what to be the cause of these sounds?

A

Partial intestinal obstruction

49
Q

A client is complaining of pain in the right upper quadrant and also in the right shoulder. Which organ would the nurse suspect as being involved?

A

Gallbladder

50
Q

Assessment of a client’s abdomen reveals a positive Murphy’s sign. Which of the following would the nurse suspect?

A

Cholecystitis

Inflammation of the gallbladder,

51
Q

The nurse assess for kidney tenderness at what location?

A

Costovertebral angle

52
Q

To palpate the spleen of an adult client, the nurse should begin the abdominal assessment of the client at the

A

left upper quadrant.

53
Q

A nurse determines that the liver span of an older adult male client measures 6 cm at the MCL. How would the nurse would interpret this finding?

A

Normal Liver size.

The normal liver span is 6 to 12 cm, so this is a normal finding.

54
Q

The nurse is evaluating a new nursing graduate’s ability to perform a rebound tenderness test for suspected appendicitis. The nurse determines correct technique when the new graduate is observed pressing deeply at which anatomic location?

A
  • Right lower quadrant

The appendix is located in the right lower quadrant. If the client has appendicitis, pressing deeply in this location with a sudden release of pressure will elicit a sharp, stabbing pain, which is called “rebound tenderness.”

55
Q

The nurse is percussing a client’s abdomen. What predominant sound should the nurse expect to hear over the majority of the abdomen?

A

Tympany

56
Q

The pancreas of an adult client is located

A

deep in the upper abdomen and is not normally palpable

57
Q

What additional history questions you might inquire about for young (teenage) adults?

A

nutrition
activity and exercises
recent weight loss and gain

58
Q

Pyrosis

A

heartburn

59
Q

Eructation

A

belching

commonly known as burping

60
Q
  • Food Intolerance
A

a negative reaction to food that doesn’t involve the immune system

61
Q

Hematemesis

A

vomiting blood

62
Q

Black stools vs. gray stools vs. red stools

A

Blck-blood in upper GI tract or iron supplements

Gray-hepatitis

red-lower GI bleed

63
Q

Hepatomegaly

A

enlargement of the liver

64
Q
  1. What is the rationale to initiate the abdominal auscultation in the right lower quadrant (RLQ)?
A

because this is the location of the ileocecal valve, which is a muscular sphincter that allows contents to move from the ileum of the small intestine to the cecum of the large intestine.

65
Q

Where is the aorta locate?

A

The let of midline in upper part of abdomen.

66
Q

What is the hypoactive?

A

No Bowl Sound within 30 seconds for each quadrant
Peritonitis

67
Q

What is the hyperactive?

A

Borborygmi often can be heard w/o a stethoscope
gastroenteritis

68
Q

What is the gastroenteritis?

A

An intestinal infection marked by diarrhea, cramps, nausea, vomiting, and fever

69
Q

How often should you hear bowel sounds?

A

5-30 per minute

Health assessment (10 decks)

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