Week 4: Abdominal Assessment & Bowl Care Flashcards
What body organs are examined in an abdominal assessment?
Lower GI tract, liver, stomach, uterus, ovaries, kidneys, and bladder.
What landmark is used to palpate the kidneys and the liver?
Below the lowest rib. Liver anteriorly on the R upper quadrant and kidney’s posteriorly on the opposite side of the spine beneath each last rib.
What does the inspection component of abdominal assessment include?
Checking:
Skin Umbilicus Contour and Symmetry Enlarged organs or masses Movement or Pulsations
When inspecting the skin during the abdominal assessment, what does bruising indicate?
Accidental injury, physical abuse, or a type of bleeding disorder
When inspecting the skin during the abdominal assessment, what are examples of unexpected findings?
Generalized color change such as in jaundice or cyanosis
When inspecting the skin during the abdominal assessment, should we ask about injections and why?
Yes. Ask pt’s about self-administered injections (e.g LMWH or insulin) as they could lead to mild bruising
What does a glistening, taut (tight) appearance to the abdomen indicate when inspecting the skin during the abdominal assessment?
Indicates ASCITES which is an abnormal buildup of fluid in the abdomen
During an abdominal skin inspection, what are you primarily checking for?
Check for color, scars, venous patterns, lesions, striae (stretch marks)
During an abdominal umbilicus inspection, what are you primarily checking for?
Check for position, shape, color, signs of inflammation, discharge, or protruding masses.
During an abdominal contour and symmetry inspection, what are you primarily checking for?
Contour, symmetry, and surface motion of the abdomen, noting any masses, bulging, or distention (can be caused by gas, tumour, or fluid)
If distension if present, a measurement of the abdomen can be done at the umbilicus and recorded periodically to track changes.
During an abdominal organ inspection, what are you primarily checking for?
Smoothness and symmetry of the abdomen. Ask pt to take a deep breath and hold. If any bulges are suspected, get pt to lift the head off the bed, so that they become more apparent.
During an abdominal ‘movement or pulsation’ inspection, what are you primarily checking for?
Movement of the abdomen during respiration.
Those in severe pain have diminished respiratory movement and tighten abdominal muscles to guard against the pain.
What increases bowel motility (hyperactive sounds during auscultation)?
inflammation of the bowel anxiety diarrhea bleeding excessive ingestion of laxatives reaction to certain foods
What are you auscultating for during an abdominal assessment?
Bowel sounds (w/ diaphragm of a stethoscope) Vascular sounds (w/bell of a stethoscope)
What is a bowel sound?
The audible sound heard with a stethoscope due to passage of air or fluid from peristalsis.
How are bowel sounds described as?
Normal
Audible
Absent
Hypoactive (paralytic ileus - intestinal blockage caused by damaged nerves/muscles)
Hyperactive (borborygmi - a rumbling or gurgling noise made by the movement of fluid and gas in the intestines)
How long is auscultation performed for?
5-20 seconds in each of the four quadrants.
For at least 5 mins if determining absent bowel sounds.
Always warm the stethoscope diaphragm.
What is the purpose of palpitation in the abdominal assessment?
To detect areas of tenderness, distension, or mass
How do you palpate the abdomen?
- light palpitation with pal and fingers extended on all 4 quadrants.
- to determine if the abdomen is soft and non-tender or abdomen is firm/rigid with discomfort
Good to know:
Important steps to remember forr rectal suppositories administration:
- compare label of med 2x with MAR during med preparation
- identify pt using at least 2 identifiers
- Sims position
- check for rectal bleeding
- check for the presence of feces
- lubricate the rounded end of suppositories + index finger of the dominant hand
- ask pt to take slow deep breaths through the mouth and relax the anal sphincter
- insert into anus 10 cm deep
- remove finger/clean anal area
- pt to remain in sims position for 5 mins
- if suppository is a laxative or fecal softener than place call bell within reach of pt
- document
Good to know:
In order to determine a health history of a patient’s bowel elimination, what factors should be considered?
- determine pt’s usual bowel patterns
- pt’s description of usual stool
- identify routines followed to promote normal bowel elimination
- assessment of the use of laxatives, suppositories, or enemas
- assessment of cognitive abilities
- changes in appetite
- diet history
- description of daily fluid intake
- hx of surgery/illness to GI tract
- medication hx
- emotional state
- exercise hx
- hx of pain/discomfort
- environment and adaptive aids
- mobility and dexterity
- presence and status of bowel diversions (i.e ostomy bag)
What medical factors alter patterns of bowel elimination?
- age-related changes
- infectious disease (i.e rotavirus (viral) - vomiting/watery stools; c. diff (bacterial) - diarrhea)
- irritable bowel syndrome
- inflammatory bowel disease (2 types - Ulcerative Colitis and Crohn’s Disease)
- DM
- pain
- pelvic floor trauma (caused to women by pregnancy, labor/delivery, aging)
- surgery/anesthesia
- enteral feeding
- meds
- acute illness
What are some personal factors that could contribute to changes in bowel movement?
- dietary patterns
- fluid intake
- personal habits
- activity and exercise
- emotions
- Tenemos (repetitive feelings to defecate)
- use of laxatives
- hemorrhoids
- belching, bloating, and flatulence
- nausea/vomiting
Abdominal assessment Bowel habits Last bowel movement Frequency Color and consistency pain before, during, or after defecation Sense of incomplete emptying of bowel movements Use of laxatives Hemorrhoids Belching, bloating, and flatulence Nausea/vomiting
These are all part of what?
Assessment and Data Gathering on pt for bowel elimination
