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HEALTH ASSESSMENT > Module 05: Anterior and Posterior Thorax (Part 02) > Flashcards

Module 05: Anterior and Posterior Thorax (Part 02) Flashcards

1
Q

When assessing the abdomen, what should be the sequence of assessment techniques?

A

(1) Inspection
(2) Auscultation
(3) Percussion
(4) Palpation

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2
Q

What are the nine (9) regions of the abdomen?

A

(1) Right hypochondriac region
(2) Left hypochondriac region
(3) Epigastric region
(4) Right lumbar region
(5) Left lumbar region
(6) Umbilical region
(7) Right iliac region
(8) Left iliac region
(9) Hypogastric region

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3
Q

How would you describe the sequence of assessment techniques when conducting the abdominal examination?

A

In abdominal assessment, AUSCULTATION COMES AFTER INSPECTION because bowel sounds could be affected in percussion and palpation.

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4
Q

This is characterized as solid.; found in areas like the liver, pancreas, spleen, adrenal glands. kidneys, ovaries, and uterus.

A

Visceral Solid

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5
Q

This is characterized as hollow; found in areas like the stomach, gallbladder.

A

Viscera Hollow

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6
Q

This lines the diaphragm, anterior and posterior abdominal wall (inferior includes the uterus, part of the bladder and part of the rectum).

A

Parietal Peritoneum

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7
Q

This lines the liver, stomach, small and large intestines.

A

Visceral Peritoneum

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8
Q

This medical condition is when the colon ruptures (similar to appendicitis); the leak in peritoneum can cause a severe type of ___________.

A

Peritonitis (The peritoneum is very sensitive to infection).

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9
Q

What are the different functions of the abdominal wall?

A

(1) Protect internal organs
(2) Allow normal compression of internal organs during functional activities: coughing and sneezing; urination and
defecation; childbirth

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10
Q

What are the three (3) muscle layers?

A

3 muscle layers extend from back, around flanks, to front: external and internal abdominus oblique, transverse
abdominus

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11
Q

What are the two (2) layers of fat?

A

(1) Visceral
(2) Subcutaneous

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12
Q

This fat layer is inside; it thickens when you eat a lot of carbohydrates and sweets.

A

Visceral Fat

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13
Q

This fat layer is outside; not as thick as visceral; grows bigger when you eat too much calories.

A

Subcutaneous Fat (As we get older, the subcutaneous and visceral thickens both ways)

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14
Q

Palpation of abdominal viscera depends on:

A

(1) Location
(2) Structural consistency
(3) Size

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15
Q

What should the nurse avoid palpating during the abdominal examination?

A

(1) Viscera normally NOT PALPABLE: pancreas, spleen, stomach, gallbladder, small intestine
(2) You CANNOT palpate kidney, only the tip of it on a VERY very skinny patient

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16
Q

This contains the abdominal aorta; right and left iliac arteries - which are responsible for supplying blood in the lower extremities.

A

Vascular structures

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17
Q

What are the four (4) quadrants?

A

(1) RUQ
(2) LUQ
(3) RLQ
(4) LLQ

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18
Q

What are the two (2) imaginary lines?

A

(1) Vertical or midline
(2) Horizontal or lateral

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19
Q

What should we use when listening to bowel sounds?

A

Four (4) quadrants
(1) We use this in listening in bowel sounds
(2) The middle point should be your UMBILICUS
(3) Patient should be laying down

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20
Q

How should the nurse interview the client?

A

(1) Collecting subjective data
(a) Interview approach (COLDSPA)
- History of current health problem, past health, family
- Pain level

(b) Lifestyle and health practice
- Eating patterns
- Bowel habits

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21
Q

What are the equipment and supplies needed for abdominal assessment?

A

(1) Small pillow
(2) Centimeter ruler, marking pen
(3) Stethoscope
(4) Gloves
(5) Hand sanitizer
(6) Extra towel or sheet for more cover

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22
Q

Enumerate the sequence of assessment.

A

(1) Inspect abdominal skin and overall contour and symmetry
(2) Auscultate after inspection and before percussion
(3) Percussion
(4) Palpation

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23
Q

How should the nurse inspect?

A

(1) Exam evaluates: skin, stomach, bowel, liver, kidneys, aorta, bladder
(2) Common abnormal findings: abdominal edema (ascites); abdominal masses (growths or constipation); unusual pulsations; pain

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24
Q

How should the nurse maintain patient privacy?

A

(1) Cover patient’s chest (especially for women)
(2) Expose abdomen from xiphoid process until above the pubis
(3) Cover lower part of the body with bed sheet/blanket

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25
Q

How should the nurse position the client?

A

(1) Supine position
(2) Knees slightly bent with pillow under the knees
(3) Arms on side or hands on chest

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26
Q

What should the nurse inspect when conducting the abdominal examination?

A

(1) Inspect skin
(a) Lesions
(b) Bulging hernia
(c) Tattoos
(d) Scars from old surgeries

(2) Skin conditions
(a) Pulsation
(b) Movements

27
Q

What are the nurse’s normal and abnormal findings when conducting the abdominal examination (inspection)?

A

(1) Normal: Rounded, shape is round, flat, no bulging hernia, no scars
(2) Abnormal: Distended (Stomach is hard and big)

28
Q

This medical condition is usually associated with abdominal obstruction, nausea, and vomiting.

A

Enlargement of the Abdomen (Tumor, Peritonitis, and Bowel Perforations)

29
Q

This type of abdominal pain is poorly defined; localized or intermittent; described as dull achy, burning, cramping and colicky pain.

A

Visceral Pain (Usually associated with diverticulitis and intestinal distention)

30
Q

This type of abdominal pain is usually described as localized and as severe and steady pain.

A

Parietal Pain (usually associated with appendicitis and peritonitis)

31
Q

This type of abdominal pain transpires when the pain travels from the primary site.

A

Referred Pain

32
Q

This type of abdominal pain is usually associated with shoulder pain.

A

Air-trapped

33
Q

What are the general signs and symptoms of abdominal pain?

A

(1) Nausea
(2) Vomiting
(3) Diarrhea
(4) Constipation
(5) Anorexia
(6) Distention

34
Q

This is an excess scar tissue that results from trauma or surgery and are more common in African Americans and Asians.

A

Keloids

35
Q

This abdominal hernia is characterized to transpire in no longer than three months; it is non-tender and there is no change in skin color.

A

Chronic

36
Q

This type of abdominal hernia is characterized to have acute pain present; usually with bluish discoloration and requires immediate surgery.

A

Acute (Strangulated Hernia)

37
Q

How should the nurse auscultate the abdominal blood vessels?

A

Listen with the bell of the stethoscope

Normal - No hums or bruits
Abnormal - Hums and bruits (+)

38
Q

What are the different abdominal blood vessels?

A

(1) Renal Arteries: Left and Right
(2) Abdominal Aorta
(3) Umbilical
(4) Iliac Arteries: Left and Right
(5) Femoral Arteries: Left and Right

39
Q

How should the nurse auscultate the abdomen for bowel sounds?

A

(1) Position patient flat in bed
(2) Listen with diaphragm of the stethoscope for 15 seconds on each 4 quadrants and add total number of sounds (total 60 seconds)
(3) Normal: High pitch quirks, gurgles and clicks present on all quadrants; usually hyperactive on left upper quadrant and less active on right lower quadrant

40
Q

How should the nurse auscultate for abdominal sounds?

A

(1) Avoid painful areas (e.g., Surgical sites)
(2) Press your stethoscope slowly and deep
(3) Auscultate all four quadrants for 15 seconds each quadrant (count number of gurgles, quirks, air-sounds per quadrant)

41
Q

This is characterized to be a low pitched murmur like sound.

A

Bruits

42
Q

What are the normal and abnormal findings for auscultating bowl sounds?

A

Normal findings
(1) Normal BS per min = 5 to 35/ min normoactive (WNS - Within Normal Limits)
(2) Abnormal
(a) Less than 5 = hypoactive BS (post-op)
(b) More than 35 = hyperactive BS (diarrhea)

In charting:
(1) Write “Less than 5 hypoactive, patient is post -op”
(2) “More than 35 hyperactive, patient is having diarrhea”

Reminder: Persons with no bowel sounds at all should NOT be fed (If fed, patient will need to undergo colostomy)

43
Q

How should the nurse percuss the abdomen during abdominal examination?

A

Percuss abdomen
(1) Up and down or zig-zag pattern
(2) Put left middle finger firmly flat on the abdomen and percuss with tip of Rt middle finger 2 times. Repeat in sequence with each change of your placement

(You should hear 2 sounds: tympanic or dull sounds)

44
Q

Where are tympanic sounds heard?

A

Stomach (associated with gastric bubble)

45
Q

Where are dull sounds heard?

A

Liver, spleen, and sigmoid

46
Q

These sounds are heard on all four (4) quadrants, the loudest is on the left upper quadrant.

A

Tympanic

47
Q

These sounds are heard on the upper most right quadrant (liver) ad the urinary bladder are (especially when the bladder is full).

A

Dull sound

48
Q

This type of palpation is characterized to be light and is done over the four (4) quadrants to note for areas of tenderness.

A

Manual (Umbilicus, aorta, liver, spleen, kidneys and urinary bladder)

49
Q

This type of palpations is characterized to be deeper; the nurse moves the upper hand or fingers while bottom stays relax; the nurse uses the finger breadth to measure area of mass felt.

A

Bi manual

50
Q

How should the nurse palpate the liver edges?

A

(1) Locate the anatomical landmarks: xiphoid, midclavicular, and end of ribs)
(2) Press right hand on the area below right ribs deeply; press from midclavicular down to the end of the ribs.
(3) Place the left hand under the left hand under the posterior area of the liver applying upward light pressure
(4) Ask patient to take a deep breath and hold for 2-3 seconds and apply deeper rubbing pressure on your right hand as the patient inhales

51
Q

What method is use to palpate the liver edges?

A

Hook Method

52
Q

What are the normal findings upon palpating the edges of the liver?

A

Normal: Usually, edges are normal size and liver is not felt; edges of the liver may be felt on patients who are slim

53
Q

How does the nurse measure the liver span?

A

(1) Start percussion from upper midclavicular ICS of chest downward until dullness is heard; mark site with a pen
(2) Percuss lower right midclavicular area going upward until dullness is heard; mark site
(3) Measure the span of the liver with ruler

54
Q

Normal liver span.

A

6 to 12 cm

55
Q

This test is for the gallbladder; test for shifting dullness by percussing from the midline to flank.

A

Murphy’s sign (for cholecystitis)

56
Q

This is a second special technique to detect ascites. In this the client should remain supine while the nurse firmly places the palmar surface of his fingers and hand against one side of the client’s abdomen. The nurse then uses their other hand to tap the opposite side of the abdominal wall.

A

Fluid Wave Test

57
Q

What are the tests used to check for appendicitis?

A

(1) Rebound tenderness and Rovsing’s sign
(2 Referred rebound tenderness
(3) Psoas sign
(4) Obturator sign
(5) Hypersensitivity test

58
Q

What are the different sites of pulsations?

A

(1) Temporal
(2) Radial
(3) Brachial
(4) Popliteal
(5) Posterior tibial
(6) Dorsalis Pedis

(Normal: Equally strong; 5/5)

59
Q

This type of test for appendicitis is when the nurse palpates the abdomen deeply at 90 degrees away from the painful or tender area.

A

Rebound Tenderness

60
Q

This type of test for appendicitis is when the nurse palpates deeply into the LLQ and quickly releases the pressure.

A

Referred Rebound Tenderness

61
Q

This type of test for appendicitis is when the nurse asks the client to lie on the left side and hyperextends the right leg of the client.

A

Psoas Sign

62
Q

This type of test for appendicitis is when the nurse supports the client’s knee and ankle. And flexes the hip and the knee and rotate the leg internally and externally.

A

Obturator sign

63
Q

This type of test for appendicitis is when the nurse strokes the abdomen with a sharp object or grasps a fold of the skin with her thumb and index finger and quickly let go to not for pain and exaggerated sensation.

A

Hypersensitivity Test

HEALTH ASSESSMENT (12 decks)

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