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NUA 311: Holistic Assessment In Nursing > Week 5 > Flashcards

Week 5 Flashcards

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1
Q

What are the 3 muscle layers from back, around flanks, to the front of the abdomen

A
  1. external abdominus obliques
  2. internal abdominus obliques
  3. transverse abdominus
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2
Q

Why are the liver and spleen difficult to palpate unless they are enlarged?

A

because they are located up under the rib cage

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3
Q

Solid vs hollow viscera

A

Solid - organs that maintain their shape consistently

Hollow - organs that can change shape

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4
Q

Solid Viscera examples (7)

A 
liver
pancreas
spleen
adrenal glands
kidneys 
ovaries
uterus
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5
Q

Hollow viscera examples

A 
Stomach
Gallbladder
Small intestine 
Colon (large intestine)
bladder
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6
Q

pancreas anatomy and location

A

soft, lobulated gland behind the stomach

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7
Q

kindey

A

Bean-shaped

retroperitoneal, or posterior to abdominal contents

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8
Q

Why does the right kindey rest 1-2 cm lower than left kidney?

A

because of placement of liver

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9
Q

abdominal well is divided into ____ quadrants; how is it divided?

A

4 quadrants; divided by a vertical and horizontal line bisecting umbilicus

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10
Q

When the abdomen is divided into 4 quadrants by a vertical and horizontal line bisecting umbilicus, what are the quadrants termed?

A

Right upper quadrant (RUQ)
Left upper quadrant (RUQ)
Left lower quadrant (LLQ)
Right lower quadrant (RLQ)

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11
Q

if the abdomen was drawn like a tic-tac-toe board, what are the middle rows called, starting at the top and going down

A

Epigastric
umbilical
hypogastric or suprapubic

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12
Q

What organs are in the Right upper quadrant (RUQ)

A 
liver gallbladder
duodenum
head of pancreas
right kidney and adrenal gland 
hepatic flexure of colon
part of ascending and transverse color
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13
Q

What organs are in the left upper quadrant (LUQ)

A 
Stomach
spleen
left lobe of liver
body of pancreas
left kidney and adrenal gland
splenic flexure of color 
part of transverse and descending colon
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14
Q

What organs are in the Right lower quadrant (RLQ)

A 
cecum 
appendix
right ovary and tube
right ureter
right spermatic cord
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15
Q

What organs are in the Left lower quadrant (LLQ)

A 
part of descending color
sigmoid colon
left ovary and tube
left ureter 
left spermatic cord
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16
Q

What are 3 midline organs

A

aorta
uterus, if enlarged
bladder, if distended

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17
Q

Developmental Competence: Pregnant Women and morning sickness

A

n/v or “morning sickness” is an early sign of pregnancy for most pregnant women, starting between first and second missed periods

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18
Q

morning sickness: cause

A

unknown; may be due to hormonal changes, such as production of human chorionic gonadotropin (hCG)

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19
Q

morning sickness s/s

A

n/v

“acid indigestion” (heartburn aka pyrosis) causes by esophageal reflux

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20
Q

Developmental Competence: Pregnant Women - describe gastrointestinal mobility

A

it decreases, which prolongs gastric emptying time

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21
Q

Developmental Competence: Pregnant Women – how does decreased motility cause constipation

A

decreased motility causes more water to be reabsorbed from colon, which leads to constipation

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22
Q

Developmental Competence: Pregnant Women – what may leave preg women at increased risk of hemorrhoids?

A

constipation and increased venous pressure

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23
Q

Developmental Competence: Pregnant Women – how are the positioning of the organs differ?

A

Enlarging uterus displaces intestine upward and posteriorly

appendix displaced up and to the right

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24
Q

Developmental Competence: Pregnant Women – bowel sounds

A

diminished

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25
Q

Developmental Competence: Pregnant Women – skin changes

A

skin changes on abdomen include striae and linea rigra

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26
Q

Developmental Competence: Aging Adults

– impacts of changes of the GI system with aging

A

changes of the GI system with aging, but most do not significantly affect function as long as no disease is present

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27
Q

Developmental Competence: Aging Adults

salvation

A

decreases, leading to dry mouth and decreased sense of taste

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28
Q

Developmental Competence: Aging Adults

- gastric emptying

A

esophageal emptying and gastric acid secretion are delayed

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29
Q

Developmental Competence: Aging Adults - gallbladder

A

increased incidence of gallstones

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30
Q

Developmental Competence: Aging Adults - liver function

A

although liver size decreases, most liver function remain normal; however, drug metabolism is impaired

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31
Q

Developmental Competence: Aging Adults - BM

A

aging adults often report constipation

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32
Q

Developmental Competence: Aging Adults - appearance in abd.

A

aging alters appearance of abdominal wall

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33
Q

Common causes of constipation

A 
decreased PA
low h20
low fiber 
medications
IBS
bowel obstruction
hypothyroidism 
age
inadequate toilet facilities; hard time ambulating to toilet may cause person to deliberately retain still until it becomes hard and difficult to pass
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34
Q

Visceral pain

A

f

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35
Q

Parietal pain

A

g

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36
Q

referred pain

A

f

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37
Q

Abdominal assessment - auscultate or or palpate first?

A

auscultate prior to palpation and percussion

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38
Q

inspection of abdomen: contour

A

Stand on person’s right side and look down at abdomen. Then, stoop or sit to gaze at abdomen. Your head should be slightly higher than the abdomen. Determine profile from rib margin to pubic bone; contour describes nutritional state and normally ranges from flat to rounded

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39
Q

Inspection of abdomen: symmetry

A

Shine a light across abdomen toward you, or shine it lengthwise across the person
– abdomen should be symmetric bilaterally

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40
Q

Contour of abdomen: Flat

A

abdoment remains flat when client is lying supine

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41
Q

Contour of abdomen: Scaphoid

A

the lower area of the abdomen is sunkent in

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42
Q

Contour of abdomen: rounded

A

the lower area of the abdomen pops out a little bit

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43
Q

Contour of abdomen: Protuberant

A

the entire stomach is pushed out

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44
Q

Inspection of Abdomen: umbillicus

A

Normally it is midline and inverted, with no sign of discoloration, inflammation or hernia

45
Q

Inspection of Abdomen: Skin

A

smooth and same color
fine venous network may be visible in this people
good turgor

46
Q

Why do striae occur

A

occur when elastic fibers in reticular layer of skin are broken after rapid or prolonged stretching (pregnancy, weight gain)
- new are pink or blue, then they turn silvery white

47
Q

Inspection of Abdomen: scars

A

if scar is present, draw the location in persons chart, indicating length in cm

48
Q

Inspection of Abdomen: pulsations or movement

A

normally, you may see pulsations from aorta beneath skin in epigastric area, particularly in this persons with good muscle wall relaxation

49
Q

Inspection of Abdomen: hair distribution

A

pattern of pubic hair growth normally has diamond shape in adult males and in inverted triangle in adult females

50
Q

Inspection of Abdomen: Demeanor

A

comfortable person is relaxed quietly on examining table and has a benign facial expression and slow, even respirations

51
Q

Auscultation of bowel and vascular sounds - why is this first?

A

because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds

52
Q

what part of stethoscope do we use for auscultation of abdomen?

A

diaphragm with light pressure

53
Q

Where do we begin auscultating the abdomen?

A

RLQ at ileocecal valve because bowel sounds are normally always present here

54
Q

how many bowel sounds should be heard per minute?

A

5-30

55
Q

What do bowel sounds originate from

A

movement of air and fluid through small intestine

56
Q

borborygmus

A

the sound of hyper-peristalsis

57
Q

how long should you listen if you are not hearing any bowel sounds

A

5 minutes

58
Q

Costovertebral angle tenderness - assessing kidney

A

to assess kidney, place one hand over 12th rib the the costovertebral angle on back

59
Q

Ascites

A

free fluid in the peritoneal cavity

60
Q

why might you think someone has ascites

A

distended abdomen, buldging, flanks, and an umbilucus that is protruding and displaced downward

61
Q

how can you differentiate ascites from gaseous distention

A

fluid wave test

shifting dullness test

62
Q

Palpate Surface and Deep Areas

A

judge size, location, and consistency of certain organs and screen for an abdominal mass or tenderness

because most people are naturally inclined to protect abdomen, you need to use additional measures to enhance complete muscle relaxation

63
Q

how do you perform light palpation of the abdomen

A

make gentle rotary motion, sliding fingers and skin together

– objective is not to search for organs but to form an overall impression of skin surface and superficial musculature

– with first four fingers close together, depress skin about 1 cm, then lift fingers (do not drag), and move clockwise to next location and around abdomen

64
Q

how do you perform deep palpation

A

same technique as light palpation but push down 5-8 cm (2-3 inches)

moving clockwiese

65
Q

light and deep palpation of abdomen: if you ID a mass, what should you note

A 
location
size
shape
consistency
surface (smooth, nodular)
mobility
pulsality 
tenderness 
-- rebound tenderness
66
Q

how would you palpate the liver

A

place left hand under person’s back parellel to 11th and 12th ribs and lift up to support abdominal contents

  • place right hang on RUQ with fingers parellel to midline
  • push deeply down and under right costal margin
67
Q

palpation of spleen

A

usually not palpable - must be enlarged three times is normal size to be felt

68
Q

how to search for spleen

A

reach your left hand over abdomen and behind left side at the 11 and 12 ribs

life up for support; place your right hand obliquely with LUQ with fingers pointing toward left axilla and just inferior to rib margin

push hand deeply down and under left costal margin, ask person to take deep breath

you should feel nothing firm

69
Q

what would you feel if you were palpating the spleen and it it enlraged

A

when enlarged, spleen slides out and bumps fingertups

70
Q

palpation of aorta

A

using opposing thumbs and fingers, palpate aortic pulsation in upper abdomen slightly to left midline

71
Q

how big is aorta pulse in adult

A

normally 2.5 to 4 cm wide in adult and pulsates in an anterior direction

72
Q

causes of abdominal distention

A 
tumor
obesity
air or gas
ascites
ovarian cyst
pregnancy
feces
73
Q

common types of hernia

A

umbilical hernia
epigastric hernia
incisional hernia
diastasis recti

74
Q

diastasis recti

A

separation in the abdominal muscle that is detached – they pull off to the side and may see a large bulge down the middle. Common in babies, abnormal in adults especially women after pregnancy.

75
Q

Abnormal findings of abdominal ausculation

A

peritoneal friction rub
arterial bruit
venous hum

76
Q

abnormal findings on palpation of organs

A

Enlarged…
liver, nodular liver, gallbladder, spleen, kidney

aortic aneurysm

77
Q

Tests for appendicitis: normal findings

A

rebound tenderness
psoas sign
obturator sign
perform hypertensitivity test

78
Q

Special abdominal tests: tests for cholecystitis

A

RUQ pain or tenderness

murphy sign

79
Q

Gastrointestinal Reflux disease (GERD): causes

A

stomach acid / contents flow back into the esophagus

– reflex irritates the lining of the esophagus

80
Q

Gastrointestinal Reflux disease (GERD): chronic irritations

A
  • esophageal structure (narrowing)
  • esophageal ulcer
  • barret esophagus (precancerous)
81
Q

Gastrointestinal Reflux disease (GERD): s/s

A 
horseness
laryngitis
chronic, dry cough
asthma or worsening asthma 
feeling as a lump in throat
 sudden increase in saliva
halitosis
earaches
chest pain/discomfort
82
Q

Risk assessment for Gastrointestinal Reflux disease (GERD):

A 
obesity
asthma
hiatal hernia
diabetes
pregnancy
delayed stomach emptying
smokings
ct disorders
dry mouth
alc. consumption
83
Q

Summary checklist – Abdomen Examinatiion

A
  1. Inspection
    - contour, symmetry, umbillicus, skin, pulsations or movement, hair distribution, and demeanor
  2. ausculation
    - bowel sounds; note any vascular sounds
  3. percussion
    - all 4 quadrants and borders of liver and spleen
  4. palpation
    light and deep palpation in all 4 quadrants, and palpate for liver and spleen
84
Q

flexion

A

bending limb at joint

85
Q

extension

A

straightening limb at joint

86
Q

abduction

A

moving limb away from midline of body

87
Q

adduction

A

moving limb toward midline of body

88
Q

pronation

A

turning forearm so that palm is down

89
Q

supination

A

turning forearm so that palm is up

90
Q

circumduction

A

moving arm in circle around shoulder

91
Q

inversation

A

moving sole of foot inward at ankle

92
Q

eversion

A

moving sole of foot outward at ankle

93
Q

rotation

A

moving head around central axis

94
Q

protraction

A

moving body part forward, parellel to groun

95
Q

retraction

A

moving body part backward, parellel to ground

96
Q

elevation

A

raising body part

97
Q

depression

A

lowing a body part

98
Q

what has a fetus formed by 3 months

A

by 3 months, fetus has formed skeleton of cartilage

99
Q

describe the growth of bone in infants and children

A

bone growth continues rapidly during infancy and steadily in childhood, until the adolscent growth spurt closes at age 20

100
Q

what causes increased mobility in joints for pregnant women

A

increased levels of circulating hormones (estrogen, relaxin from corpus letuem, and corticosteriods) cause increased mobility in joints

101
Q

what contributes to noticeable changes in maternal posture

A

increased mobility in sacroilliac, sacrococcygeal and symphysis pubis joints in pelvis contributes to noticeable changes in maternal posture

102
Q

What is the most characteritic change in the sketetal muscle in preg women

A

progressive lordosis, which compensates for enlarging fetus by shifting weight farther back on lower extremities

103
Q

skeletal muscle changes in aging adults

A

postural changes - decreased height

reabsoption occurs more rapidly than deposition

104
Q

ortolani’s maneuver

A

checks infants hips for congenital dislocation; should be done at every visit until infant is one year old

105
Q

what to inspect for skeletal muscles in infants hands and arms

A

inspect hands noting shape, number and position of fingers and palmar creases

palpate length of clavicles; the bone most frequently is fractured during birth

106
Q

what to inspect for skeletal muscles in infants back

A

Note the C-curve, length of spine for tuft of hair, dimple in midline, cycst, or mass

107
Q

kyphosis

A

bad posture; backward head tilt to compensate for poor posture in older adults

108
Q

Assessment of musculoskeletal system

A

Inspect:

  • size / contour of joint
  • inflammatory conditions
  • rheumatoid arthritis
  • ankylosing spondylitis
  • degenerative conditions
    • osteoarthritis / osteoporosis
  • skin color and characteristics

Palpation of joint area
- skin, muscles, bony articulations and joint capsules

ROM
active, passive
- measure with goniometer

Muscle testing

  • strength testing bilaterally
  • with and without gravity
  • 0-5 grade

NUA 311: Holistic Assessment In Nursing (5 decks)

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