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N143 !!!! > Module 3: Abdominal assessment > Flashcards

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
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2
Q

what is bacteruria

A

bacteria in urine

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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
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4
Q

What is type 1 in the bristol stool chart

A

Separate hard lumps - severe constipation

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5
Q

what is type 2 poop

A

lumpy and sausage like - mild constipation

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6
Q

what is type 3 poop

A

sausage shape with cracks on surface (normal)

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7
Q

what is type 4 poop

A

a smooth soft sausage or snake - normal

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8
Q

what is type 5 poop

A

soft blobs with clear cut edges - lacking fibre

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9
Q

what is type 6 poop

A

mostly mush with ragged edges -milk diarrhea

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10
Q

what is type 7 poop

A

liquid consistency with no solid piece - severe diarrhea

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11
Q

what is melena

A

black tarry stools which usually occur because of upper GI tract bleeding

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12
Q

what is steatorrhea

A

bulky, pale foul smelling: float bc of gas. Caused by malabsorption

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13
Q

What should you auscultate for

A

bowel sounds, begin gin in lower R quad. (normal: gurgles ever 5-30 seconds)

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14
Q

What is borborygmi

A

audible bowel sounds without a stethoscope

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15
Q

what is rebound tenderness

A

when you remove your hand and it hurts the pt.

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16
Q

what is light palpation for

A

-Tenderness, muscular resistance, masses

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17
Q

what is deep palpation for

A

masses, tenderness, pulsations, organs, fluid in peritoneal cavity

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18
Q

what should you percuss for

A

-organs (liver & spleen) size, location, tenderness

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19
Q

what side is liver on

A

right

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20
Q

what side is speen on

A

left

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21
Q

where should you hear resonant sounds

A

colon

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22
Q

where should you hear dullness

A

liver, spleen, full bladder

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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
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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
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25
Q

what to include in abdominal assessment history

A
  • 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
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26
Q

what you should take note of about the stoma

A 
location on abdomen
color
shape
size
discharge
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27
Q

The closer to the small bowel…

A

the more watery the stool

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28
Q

the closer to the rectum…

A

the more formed the stool will be

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29
Q

Patients response to bowel diversion depends on

A
  • 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
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30
Q

what is the upper anterior boundary to the abdomen

A

XIPHOID process

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31
Q

what is the lower boundary of the abdomen

A

symphysis pubis

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32
Q

Where are the kidneys

A

Castrovertebral angle of last rib and vertebral column

T12-T13 covered by lower ribs and back muscles usually

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33
Q

what order should you do the objective in a abdomen assessment

A

inspection, auscultation, palpation, precussion

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34
Q

nursing history for abdominal assessment

A
  • 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
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35
Q

what are some risk factors for HBV

A
  • health care occupation
  • hemodialysis
  • IV drugs, household, sexual contact
  • international traveler
  • more than 2 sexual partners a year
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36
Q

what is abdominal splinting

A

lying in fetal position of restless in bed guarding

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37
Q

how do u look for abdominal movement or shadows

A

stand on the right side, inspect from above

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38
Q

how do u look for contour of abdomen

A

sit down across from abdomen and shine light

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39
Q

what is ascites

A

fluid accumulation in abdomen

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40
Q

what does a hernia do the umbilicus

A

causes an untoward protrusion

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41
Q

stomachs can be flat, round, or concave

A

-all good as long as they’re symmetrical

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42
Q

what are 3 things that could cause distension

A

gas, tumour, fluid

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43
Q

do the flanks bulge with gas?

A

no

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44
Q

if you roll onto one side and it move.. you know that the abdomen is filled with

A

fluid

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45
Q

higher pitch over…

A

solid

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46
Q

lower pitch over…

A

hollow

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47
Q

how do men breath

A

abdominally

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48
Q

how do women breath

A

thoracically

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49
Q

what is peristalsis

A

movement of contents through intestines

50
Q

how long to listen for before u decide there is no bowel sounds

A

5 min

51
Q

what is borborygmi caused by

A

inflammation, anxiety, diarrhea, bleeding, laxatives, just certain foods

52
Q

what could it mean if you hear bruit when you hear vascular sounds

A

posible aneurysm or stenotic vessels

53
Q

how to check for kidney tenderness

A

indirect or direct percussion to assess for inflame/ tender

54
Q

how deep is light palpation

A

1cm `

55
Q

how deep is deep paplpation

A

5-8 cm

56
Q

when should you not do deep palpation

A

surgical wound, tender, abdominal masses, cucumbers, sigmoid colon, aura, or xiphloid process

57
Q

how do you know if the pt. may have an aneurysm

A

aorta pulsation will be felt laterally

58
Q

what are the physiological factors critical to bowel function

A
  • 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
Q

what is the valsalva manoeuvre

A

when you contract the abs and diaphragm via forced expiration (not recommended)

60
Q

What is the perfect defacating posture

A
  • knees higher than hips
  • lean forward
  • bulge out abdomen, straighten spin
61
Q

What are the factors that effect normal BM

A
  • Diet
  • Fluid intake
  • physical activity
  • personal bowel elimination habits
62
Q

what is fiber

A

indigestible residue

  • insoluable ( effective to prevent constipation
  • need fluid for this to work
63
Q

what is peristalsis

A

wave like motion to push food out

64
Q

what is the gastrocolic reflex

A

when you ingest food and then you need to go to the washroom

65
Q

Nursing health history for abdominal assessment

A
  • 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
Q

what could narrow or pencil poop mean

A

anal carcinoma

67
Q

What is enteritis

A

inflammation of intestine

68
Q

What are some safety precautions for digital removal of stool

A
  • can cause irritartion, bleeding, perforation of bowel wall
  • stimulates vagus nerve (decrease HR)
69
Q

What is the line down the middle of the abdomen

A

the lines alba

70
Q

what is the large strip of muscle down the midline

A

the rectus abdominnus

71
Q

Where is the liver located

A

Fills up most of upper right Quad

extends over mid clavicular line

72
Q

where is the stomach located

A

just below the diaphragm (between liver & spleen)

73
Q

where is the gallbladder located

A

rests under posterior surface of liver, lateral to right mid-clav line

74
Q

where is the small intestine

A

all 4 quadrants

75
Q

where is the spleen

A

posterolateral wall under diaphragm, parallel to 10th rib

76
Q

where is the pancreas

A

behind the stomach (L upper Quad)

77
Q

Where are the kidneys

A

posterior, 12th rip angle with vertebral column (R kidney lower than L)

78
Q

What quad is liver in

A

R Upper

79
Q

what quad gall bladder

A

R upper

80
Q

what quad duodenum

A

R upper

81
Q

what quad head of pancreas

A

R upper

82
Q

what quad R kidney

A

R upper

83
Q

what quad cecum

A

R lower

84
Q

what quad appendix

A

R lower

85
Q

What quad stomach

A

L upper

86
Q

what quad spleen

A

L upper

87
Q

what quad pancreas

A

L upper

88
Q

What quad descending colon

A

L lower

89
Q

What quad sigmoid colon

A

L lower

90
Q

What are the developmental considerations for infants and children

A
  • Liver will take up more space
  • bladder is higher
  • they are less muscular
  • 10 & under at risk for acute gastrointestinal illness
91
Q

What is gastroenteritis

A

inflammation of the stomach and intestines

92
Q

What are some developmental considerations for pregnant women

A
  • relaxed smooth muscle, decreased motility of Gi, longer gastric emptying time
  • can cause constipation and hemorroids
  • bowel sounds are diminished
93
Q

developmental considerations for older adults

A
  • 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
Q

What are some causes for constipation in elderly

A
  • less mobility
  • medication effects
  • laxatives
  • sedentary lifestyle
  • hypothyroidism
  • poor dietary habits
  • ignroing need for poop
  • polypharmacy
95
Q

drugs that can cause constiptation

A
  • anti inflammatories
  • diuretics
  • opiods
  • antiparkinsons meds
  • antacids
  • calcium or iron pills
96
Q

what is celiac disease

A

inherited auto immune disease where intestinal tissue is damaged when gluten is eaten
can lead to malabsorption, iron deficiency and osteoporosis

97
Q

what is dysphagia

A

Difficulty swallowing

98
Q

Subjective data to collect

A

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
Q

Additional history for infants and children

A

1) what Infant is fed
2) table foods
3) eating patters
4) Conspitation
5) abdominal pain
6) overweight

100
Q

Additional history for adolesents

A

1) schedule and content
2) exercise
3) underweight

101
Q

additional history for older adults

A

1) food access
2) emotional characteristics
3) recall
4) Bm’s

102
Q

When will the umbilical cord fall off by

A

2-4 weeks

103
Q

What is diastalis recti

A

separation of abs with visible bulge midline (disappears b4 child is 6)

104
Q

will you hear vascular sound when auscultating infant?

A

no

105
Q

when does a childs abdomen stop being protuberant

A

age 4

106
Q

the external sphincters are..

A

Voluntary

107
Q

the internal sphincters are..

A

involuntary

108
Q

what is occult blood

A

blood in stool that isn’t visible

109
Q

what is a stoma

A

temp or permanent artificial opening in abdominal wall

110
Q

Illeostomy

A

surgical opening of ileum

111
Q

colostomy

A

surgical opening of colon

112
Q

what kind of consistency is poop from a ileostomy

A

frequent and liquid

113
Q

what is stool from a transverse colon more like

A

more formed

114
Q

explain loop colostomy

A

Medical emergency

2 stomas, stool & mucus

115
Q

End colostomy

A

other end is removed or it becomes a pouch

116
Q

double-barrel colostomy

A

2 stomas, one is non-functioning

117
Q

Psychological considerations of colostomy

A
  • Underlying reason for an ostomy
  • presence & severity of ostomy
  • post op supportive care
  • costly, quality of life
  • comorbid complications
  • sex function- body image
118
Q

What is pyloric stenosis

A

Pyloric stenosis is a congenital defect causing narrowing of the pyloric valve.

119
Q

Four layers of large flat muscle from the..

A

ventral abdominal wall

120
Q

What is pyrosis

A

Pyrosis (heartburn) is a burning sensation in the esophagus and stomach from reflux of gastric acid.

121
Q

Which 2 foods could cause a false reading occult blood

A

raw veg

fish

N143 !!!! (4 decks)

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