Module 3: Abdominal assessment Flashcards
1
Q
Improper use of a catheter
A
- as a substitute of nursing care for a pt with incontinence
- to collect for a test or culture when pt. can voluntarily void
- as a routine for a pt. receiving epidural
- pt. request or convenience
- immobility
2
Q
what is bacteruria
A
bacteria in urine
3
Q
what should u inspect for during abdominal assessment
A
- Skin: color, scars, striae, dilated veins, rashes, lesions
- umbilicus
- shape and contour of abdomen
- peristalsis
- pulsations
4
Q
What is type 1 in the bristol stool chart
A
Separate hard lumps - severe constipation
5
Q
what is type 2 poop
A
lumpy and sausage like - mild constipation
6
Q
what is type 3 poop
A
sausage shape with cracks on surface (normal)
7
Q
what is type 4 poop
A
a smooth soft sausage or snake - normal
8
Q
what is type 5 poop
A
soft blobs with clear cut edges - lacking fibre
9
Q
what is type 6 poop
A
mostly mush with ragged edges -milk diarrhea
10
Q
what is type 7 poop
A
liquid consistency with no solid piece - severe diarrhea
11
Q
what is melena
A
black tarry stools which usually occur because of upper GI tract bleeding
12
Q
what is steatorrhea
A
bulky, pale foul smelling: float bc of gas. Caused by malabsorption
13
Q
What should you auscultate for
A
bowel sounds, begin gin in lower R quad. (normal: gurgles ever 5-30 seconds)
14
Q
What is borborygmi
A
audible bowel sounds without a stethoscope
15
Q
what is rebound tenderness
A
when you remove your hand and it hurts the pt.
16
Q
what is light palpation for
A
-Tenderness, muscular resistance, masses
17
Q
what is deep palpation for
A
masses, tenderness, pulsations, organs, fluid in peritoneal cavity
18
Q
what should you percuss for
A
-organs (liver & spleen) size, location, tenderness
19
Q
what side is liver on
A
right
20
Q
what side is speen on
A
left
21
Q
where should you hear resonant sounds
A
colon
22
Q
where should you hear dullness
A
liver, spleen, full bladder
23
Q
developmental considerations for pediatrics
A
- protuberant abdomen until 4
- liver 1-2 cm under right costal margin
- can com times feel 1-2 cm of right kidney and tip of left kidneys
24
Q
Review parts of general survey
A
age and gender signs of distress body type and posture gait and movement hygiene and grooming dress body odour affect and mood, speech
25
what to include in abdominal assessment history
- appetite
- indigenstion, nausea, vomiting
- dysphagia
- changes in bowel function
- jaundice
- pain assessment
- pain and or associated bowel changes in relation to dietary intake
- alchohol intake
- smoking
- history of disease
- sugical history
- stool freq. consistency, color, door
- stoma color, shape, size
- products used
26
what you should take note of about the stoma
```
location on abdomen
color
shape
size
discharge
```
27
The closer to the small bowel...
the more watery the stool
28
the closer to the rectum...
the more formed the stool will be
29
Patients response to bowel diversion depends on
- underlying cause for an ostomy
- presence and severity of stony complications
- presence and severity of comorbid conditions
- sexual function and other body changes
- ability to pay for ostomy supplies
- health-related quality of life
- assess to post-op supportive care and consoling
30
what is the upper anterior boundary to the abdomen
XIPHOID process
31
what is the lower boundary of the abdomen
symphysis pubis
32
Where are the kidneys
Castrovertebral angle of last rib and vertebral column
| T12-T13 covered by lower ribs and back muscles usually
33
what order should you do the objective in a abdomen assessment
inspection, auscultation, palpation, precussion
34
nursing history for abdominal assessment
- pain with symptom assess
- observe pt. movement and position
- assess normal bowel habits and stool character
- any surgery, trauma, or diagnostic tests
- recent weight changes or new intollereances
- Difficulty: swallow, belch, gas, blood, black or tarry stool, heartburn, dire, constipation
- any antinflamatories or antibiotics
- tender areas
- fam history of: cancer, kidneys disease, alcoholism, hypertension, heart disease
- preg or last period
- usual alchohol intake
35
what are some risk factors for HBV
- health care occupation
- hemodialysis
- IV drugs, household, sexual contact
- international traveler
- more than 2 sexual partners a year
36
what is abdominal splinting
lying in fetal position of restless in bed guarding
37
how do u look for abdominal movement or shadows
stand on the right side, inspect from above
38
how do u look for contour of abdomen
sit down across from abdomen and shine light
39
what is ascites
fluid accumulation in abdomen
40
what does a hernia do the umbilicus
causes an untoward protrusion
41
stomachs can be flat, round, or concave
-all good as long as they're symmetrical
42
what are 3 things that could cause distension
gas, tumour, fluid
43
do the flanks bulge with gas?
no
44
if you roll onto one side and it move.. you know that the abdomen is filled with
fluid
45
higher pitch over...
solid
46
lower pitch over...
hollow
47
how do men breath
abdominally
48
how do women breath
thoracically
49
what is peristalsis
movement of contents through intestines
50
how long to listen for before u decide there is no bowel sounds
5 min
51
what is borborygmi caused by
inflammation, anxiety, diarrhea, bleeding, laxatives, just certain foods
52
what could it mean if you hear bruit when you hear vascular sounds
posible aneurysm or stenotic vessels
53
how to check for kidney tenderness
indirect or direct percussion to assess for inflame/ tender
54
how deep is light palpation
1cm `
55
how deep is deep paplpation
5-8 cm
56
when should you not do deep palpation
surgical wound, tender, abdominal masses, cucumbers, sigmoid colon, aura, or xiphloid process
57
how do you know if the pt. may have an aneurysm
aorta pulsation will be felt laterally
58
what are the physiological factors critical to bowel function
* Acute anorectal angle
* refelexes of external & internal sphincters
* preassure in anal canal
* sensory response of rectum
* absorption of fluid in intestine
* complete evacuation of rectum
* physical and cognitive ability to get to bathroom
59
what is the valsalva manoeuvre
when you contract the abs and diaphragm via forced expiration (not recommended)
60
What is the perfect defacating posture
- knees higher than hips
- lean forward
- bulge out abdomen, straighten spin
61
What are the factors that effect normal BM
- Diet
- Fluid intake
- physical activity
- personal bowel elimination habits
62
what is fiber
indigestible residue
* insoluable ( effective to prevent constipation
* need fluid for this to work
63
what is peristalsis
wave like motion to push food out
64
what is the gastrocolic reflex
when you ingest food and then you need to go to the washroom
65
Nursing health history for abdominal assessment
- Usual
- perception of normal & abnormal
- usual pattern
- description of stool
- routines followed
- laxatives
- cognitive ability
- change in appetitie
- diet history
- fluid intake
- sugery or illness
- med hisotyr
- emotional state
- exercise
- pain
- mobility
- environment & aids
- presence and status of bowel diversions
66
what could narrow or pencil poop mean
anal carcinoma
67
What is enteritis
inflammation of intestine
68
What are some safety precautions for digital removal of stool
- can cause irritartion, bleeding, perforation of bowel wall
- stimulates vagus nerve (decrease HR)
69
What is the line down the middle of the abdomen
the lines alba
70
what is the large strip of muscle down the midline
the rectus abdominnus
71
Where is the liver located
Fills up most of upper right Quad
| extends over mid clavicular line
72
where is the stomach located
just below the diaphragm (between liver & spleen)
73
where is the gallbladder located
rests under posterior surface of liver, lateral to right mid-clav line
74
where is the small intestine
all 4 quadrants
75
where is the spleen
posterolateral wall under diaphragm, parallel to 10th rib
76
where is the pancreas
behind the stomach (L upper Quad)
77
Where are the kidneys
posterior, 12th rip angle with vertebral column (R kidney lower than L)
78
What quad is liver in
R Upper
79
what quad gall bladder
R upper
80
what quad duodenum
R upper
81
what quad head of pancreas
R upper
82
what quad R kidney
R upper
83
what quad cecum
R lower
84
what quad appendix
R lower
85
What quad stomach
L upper
86
what quad spleen
L upper
87
what quad pancreas
L upper
88
What quad descending colon
L lower
89
What quad sigmoid colon
L lower
90
What are the developmental considerations for infants and children
- Liver will take up more space
- bladder is higher
- they are less muscular
- 10 & under at risk for acute gastrointestinal illness
91
What is gastroenteritis
inflammation of the stomach and intestines
92
What are some developmental considerations for pregnant women
- relaxed smooth muscle, decreased motility of Gi, longer gastric emptying time
- can cause constipation and hemorroids
- bowel sounds are diminished
93
developmental considerations for older adults
- more fat
- less saliva
- esophageal emptying delayed
- gastric acid dec. so less absorption of minerals and vitamins
- ability to conserve water is decreased
- liver size decreased
- renal function decreased
- constipation
94
What are some causes for constipation in elderly
- less mobility
- medication effects
- laxatives
- sedentary lifestyle
- hypothyroidism
- poor dietary habits
- ignroing need for poop
- polypharmacy
95
drugs that can cause constiptation
- anti inflammatories
- diuretics
- opiods
- antiparkinsons meds
- antacids
- calcium or iron pills
96
what is celiac disease
inherited auto immune disease where intestinal tissue is damaged when gluten is eaten
can lead to malabsorption, iron deficiency and osteoporosis
97
what is dysphagia
Difficulty swallowing
98
Subjective data to collect
1) Appetitie
2) Dysphagia
3) Food intolerance
4) Abdominal pain
5) nausea/vomit
6) bowel habits
7) past abdominal history
8) Medications
9) Alcohol and tobacco
10) nutritional assessment
99
Additional history for infants and children
1) what Infant is fed
2) table foods
3) eating patters
4) Conspitation
5) abdominal pain
6) overweight
100
Additional history for adolesents
1) schedule and content
2) exercise
3) underweight
101
additional history for older adults
1) food access
2) emotional characteristics
3) recall
4) Bm's
102
When will the umbilical cord fall off by
2-4 weeks
103
What is diastalis recti
separation of abs with visible bulge midline (disappears b4 child is 6)
104
will you hear vascular sound when auscultating infant?
no
105
when does a childs abdomen stop being protuberant
age 4
106
the external sphincters are..
Voluntary
107
the internal sphincters are..
involuntary
108
what is occult blood
blood in stool that isn't visible
109
what is a stoma
temp or permanent artificial opening in abdominal wall
110
Illeostomy
surgical opening of ileum
111
colostomy
surgical opening of colon
112
what kind of consistency is poop from a ileostomy
frequent and liquid
113
what is stool from a transverse colon more like
more formed
114
explain loop colostomy
Medical emergency
| 2 stomas, stool & mucus
115
End colostomy
other end is removed or it becomes a pouch
116
double-barrel colostomy
2 stomas, one is non-functioning
117
Psychological considerations of colostomy
- Underlying reason for an ostomy
- presence & severity of ostomy
- post op supportive care
- costly, quality of life
- comorbid complications
- sex function- body image
118
What is pyloric stenosis
Pyloric stenosis is a congenital defect causing narrowing of the pyloric valve.
119
Four layers of large flat muscle from the..
ventral abdominal wall
120
What is pyrosis
Pyrosis (heartburn) is a burning sensation in the esophagus and stomach from reflux of gastric acid.
121
Which 2 foods could cause a false reading occult blood
raw veg
| fish
