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Nursing 209 > Test 3 Abdomen > Flashcards

Test 3 Abdomen Flashcards

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1
Q

Previous Health History

A
  • Previous GI problems
  • Abdominal/GI injury or surgery
  • UTI history
  • History of major illness
  • Medications such as steroids, aspirin, and Advil can also cause GI problems such as bleeding
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2
Q

Family Health History

A
  • Kidney, urinary problems
  • Colon diseases, cancer
  • Gallbladder disease
  • Malabsorption syndromes
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3
Q

Colo-rectal Cancer (CRC)

A
  • 2nd leading cause of cancer deaths in the US
  • 27,150 men and 23,110 women die each year
  • more men die for rectal cancer than women
  • known as the silent killer as symptoms to not appear until the later stages
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4
Q

CRC Warning Signs

A
  • pain, cramping, and discomfort in lower abdomen
  • cramping and pain for long periods of time
  • sudden, persistent change in stools consistency (that can’t be contributed to illness
  • Visible blood in stool (often can’t be seen)
  • Hardness in lower abdomen (persistent and stays in the same place a bad sign)
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5
Q

CRC Warning Signs Cont.

A
  • Prolonged diarrhea
  • a sense of incomplete bowel movement (BM but still feel need to go
  • Obstruction in bowel movement (stool is extruded through a smaller opening; comes out like a pencil)
  • anemia or iron defiency
  • Abrupt weight loss
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6
Q

CRC Risk factors

A
  • Older than 50
  • African American race
  • a personal history of colorectal cancer or polyps
  • inflammatory intestinal conditions
  • inherited syndromes that increase colon CA risk
  • family history of colon CA and polyps
  • low fiber, high fat diet and diet high in red meat
  • sedentary life style
  • diabetes, obesity, smoking, alcohol
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7
Q

Present Health Status

A
  • Nutrition
  • Allergies to food/meds
  • Alcohol intake (excessive drinking inc. risk)
  • Meds (steroids, anti-inflammatory, anticoagulants, can all cause bleeding and ulcers)
  • Stool Characteristics (important to know nl to have something to compare to)
  • Urinary Characteristics (know color and odor or urine and if they pain and difficulty going)
  • expose to infectious diseases
  • pregnancy
  • recent stress
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8
Q

Reasons for Seeking Care

A
  • Abdominal pain
  • Nausea
  • Vomiting
  • GERD/Indigestion
  • Diarrhea
  • Constipation
  • Dysuria (pain urinating)
  • Urinary Incontinence
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9
Q

Equipment

A
  • Stethoscope
  • Metric RUler
  • Marking pen
  • Small pillow
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10
Q

Room/Positioning

A
  • Warm room
  • have patient void
  • supine
  • pillow under head/knees
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11
Q

Note pt. getting onto bed and getting into position

A

Fetal position - doesn’t stretch out organs and cause pain
Motionless - typically indicates peritonitis
Restless - indicates colic, renal calculi

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12
Q

Examination order for abdomen

A

Inspection
Auscultation
Percussion
Palpation

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13
Q

Anatomical Mapping

A 
4 quadrants
RUQ
LUQ
RLQ
LLW
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14
Q

RUQ

A 
Liver
Gallbladder
Duodenum
Head of pancreas
R kidney and adrenal
Hepatic fixture of colon
Part of ascending and transverse colon
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15
Q

LUQ

A 
Stomach
Spleen
L lobe of liver
Body of pancreas
L kidney and adrenal
Splenic fixture of colon
Part of transverse and descending colon
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16
Q

RLQ

A 
Cecum
Appendix 
R ovary and tube
R ureter
R spermatic cord
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17
Q

LLQ

A

Part of descending colon
Sigmoid colon
L ovary and tube
L ureter

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18
Q

9 Regions

A 
Epigastric
Umbilical
Hypogastric
R. Hypochondriac
Lt. Hypochondriac
R. Lumbar
L. Lumbar
R. Inguinal (iliac)
L. Inguinal (iliac)
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19
Q

Epigastric

A

Pyloric End of stomach
Duodenum
Head of pancreas
Portion of liver

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20
Q

Umbilical

A

Omentum (fold of peritoneum connecting the stomach)
Mesentery
Lower duodenum
Jejunum and ileum

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21
Q

Hypogastric (pubic)

A

ileum
bladder
uterus (in pregnancy)

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22
Q

R. Hypochondriac

A 
Right lobe of the liver
Gallbladder
Portion of duodenum
Hepatic fixture of colon
Portion of R. kidney
R. adrenal gland
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23
Q

L. Hypochondriac

A 
Stomach
Spleen
Tail of pancreas
Splenic fixture of colon
Upper pole of left kidney
Portion of duodenum
Jejunum
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24
Q

R. Lumbar

A

Ascending colon
Lower half of right kidney
Portion of duodenum and jejunum

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25
Q

L. Lumbar

A

Descending colon
Lower half of left kidney
Portion of duodenum and jejunum

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26
Q

R. Inguinal (Iliac)

A 
Cecum
Appendix
Ileum (lower end)
Right ureter and right ovary
Right spermatic cord
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27
Q

L. Inguinal (iliac)

A

Sigmoid colon
Left ureter and L ovary
Left spermatic cord

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28
Q

Grey Turners Sign

A

Bruising in the flanks; indicates trauma to the kidney, severe pancreatitis, ruptured ectopic pregnancy

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29
Q

Striae

A

Can be a nl variation
Recent - Pinkish color
Older - white/silver
Abnormal - Blush purple from Cushings Disease

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30
Q

Cullen’s Sign

A

Blue color around or under umbilicus; indicates abnormal bleeding from trauma, ectopic pregnancy, pancreatitis, or from a leaking or ruptured abnormal aortic aneurysm

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31
Q

Petechia

A

Tiny and easier to see on abdomen; vascular disease, fat emboli

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32
Q

Keloids

A

Dense overgrowth (hypertrophy) of fibrous tissue; more common in African Americans

33
Q

Adhesion

A

Scar tissue develops in the area where they have their surgery; adhering to other organs or structures

34
Q

Vena Cava obstruction

A

Dilated, engorged veins goes from pubis bone upward

35
Q

Portal hypertension

A

Veins going in wheel barrow shape around umbilicus

36
Q

Spider Veins

A

indicative of liver damage

37
Q

Direction of Blood flow

A

Place both index fingers together on a vessel. Press down and move fingers apart
Life one finger up, note flow, repeat with the other side
The way it goes the fastest is the direction of the blood flow

38
Q

Distention

A

Unusual stretching and enlargement of abdomen; implies disease; can be symmetrical or asymmetrical distention

39
Q

6 causes of distention

A 
Fluid (ascites, hemorrhage)
Flatulence (gas)
Fat (obesity; adipose)
Feces (constipation)
Fibroid/fatal tumor
Fetus
40
Q

Distended lower third

A

Could be from extended bladder

41
Q

scapphid

A

dip in abdomen in really thin people

42
Q

distended upper half

A

stomach or liver area/swelling/ tumor/ masses

43
Q

Respiratory movement

A

Men normally breathe through their stomach
If abdominal respiration not present in men, could mean peritonitis and other abdominal problems
Women normally breathe through they chest

44
Q

Visible peristalsis

A

Progressive wavelike movement, involuntary
Normally can’t be seen
moves RIGHT TO LEFT

45
Q

Pyloric stenosis

A

Reverse peristalsis in infants; malrotation of the bowel

46
Q

Peristaltic sounds

A

High pitched gurgling, clicks
Very irregular
Occur q 5-15 seconds or 5-35 sounds per minute
Relative to when pt. last ate

47
Q

Borborygmi

A

sounds like breaking glass and water splashing

Caused by diarrhea, early bowel obstruction, laxative overuse, subsiding ileus (paralyzed bowel)

48
Q

Vascular sounds

A

Hepatic friction rub - along costal margins; under right breast
Splenic friction rub - under left breast
Aorta - medially above umbilicus
Renal artery - above umbilicus on L and R sides
Iliac artery - on hips
Venous hum - by umbilicus
Femoral - medially by quads

49
Q

Venous hums

A

low pitch, soft, continuous; could indicate obstruction of blood flow over liver of umbilicus

50
Q

Peritoneal Friction Rub

A

Grating, leather rubbing together, soft
Associated with each breath (make note where we are hearing)
Enlarged liver or spleen rubbing on organs
Could also be from other organs, an abscess or tumor

51
Q

Tympany

A

Is most common in abdomen

52
Q

Dull

A

Solid masses (organs, distended bladder)

53
Q

Liver Span

A

Percuss down on the right MCL until sound changes from resonant to dull (make a mark)
Next percuss up the right MCL until sound changes from tympany to dull (find a mark)

54
Q

Liver Span: normal findings

A

span of 6-12 cms at MCL

4-8 cms at sternal line

55
Q

Palpation

A

Substantiates other findings

56
Q

Light Palpation

A

Gentle exploration by rolling fingers
Use of flat fingers
Do not dig into pt. press in about 1 cm
Note soft or hard first. Could be soft, firm, hard, bouncy like a balloon, or board like (peritonitis)

57
Q

Moderate/Deep palpation

A

Same as light but push into patient harder and deeper (we mainly use light palpation on abdomen)
Should feel organs
Deep palpation may produce tenderness over certain areas normally; cecum sigmoid colon, is very uncommonly used

58
Q

Voluntary guarding

A

Conscious contraction of the abdominal muscles (rectus muscles). Patients anticipate a painful assessment and tense (bent knees may help this)

59
Q

Involuntary guarding

A

Involuntary tensing of the abdominal muscles to protect the inflamed or injured organs from feeling the pressure of pain (peritonitis)

60
Q

Liver Palpation

A

Use bimanual trapping or hand over hand

Have them breathe normally then deep so that the diaphragm pushes down on the liver

61
Q

Hooking Technique (Middleton’s)

A

Cup hands around ribs; not done often

62
Q

Hepatomegaly

A

Enlarged liver; pain, hard, nodular

63
Q

Gallbladder Palpation

A

Similar to liver

Located close to RMCL

64
Q

Murphy’s sign

A

Pain on inspiration while palpating under rig cage, pt. will suddenly hold breath

65
Q

Cholecystitis

A

Inflammation of the gallbladder

66
Q

Cholelithiasis

A

A gallstone

67
Q

Splenomegaly

A

Enlarged 3X the normal size with trauma, CA, mononucleosis

68
Q

Pancreas Palpation

A

Pancreas is too small to palate even if it is diseased

CA not usually found until it is advanced

69
Q

Kidney Palpation

A

Non palpable in normal adults

Usually only feel the right kidney

70
Q

Hydronephrosis

A

Fluid collecting in the kidneys (tumor)

71
Q

Ascites

A

Free fluid in the abdomen

72
Q

McBurneys Point

A

Between the umbiliucs and hip bone on the right side, a little closer to the hip bone
Rebound tenderness indicates appendicitis

73
Q

Roving’s sign

A

Same as for rebound tenderness with McBurneys Point but on the left side
Indicates peritoneal inflammation or appendicitis

74
Q

Iliopsoas Muscle Test

A

Pt supine and ask to hold the right leg
Examiner exerts moderate pressure on the lower thigh
Pt will complain of pain in the RLQ if there is peritoneal inflammation

75
Q

Obturator Muscle Test

A

Pt supine and ask them to flex the right hip 90 degrees
Grab the ankle and internally and externally rotate the lower leg, while turning the thigh inward
Will feel hypogastric pain if there is peritoneal irritation

76
Q

Pediatric Consideration

A 
Potbelly in toddler
Abdominal breathers
Pulse will be more visible and bounding in the epigastric area
Short liver span
Very ticklish
Distrustful of abdominal exams
77
Q

Older Adult Consideration

A 
Decreased saliva, gastric enzymes, acids
Decreased motility
Liver more easily palpable and smaller
Prone to constipation and diarrhea
more likely to be malnourished
Decreased bladder capacity
78
Q

Mononucleosis

A

When the spleen ruptures

Nursing 209 (9 decks)

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