Describe the inspection method and assessments made while inspecting the abdomen Quizlet
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Winningham's Critical Thinking Cases in Nursing6th EditionJulie S Snyder, Mariann M Harding 2,214 solutions Terms in this set (112)no specific cause identified, but risk factors include increased age, history of Adenoma's, high red-meat diet, high fat and low fiber diet, smoking, alcohol consumption, obesity, first degree relatives, inflammatory bowel disease, crohn's disease change in bowel habits, abdominal pain, pressure, or cramping, iron deficiency anemia due to blood loss, weakness, weight loss, rectal pressure and/or bleeding, mass in RLQ, rectal bleeding, pain, blood in stools, change in bowel habits, alternating constipation and diarrhea, nausea and vomiting Sets with similar termsWhat's the first thing you must ask the patient before starting the assessment? urinate or eliminate waste first Where must you drape the clothing to examine the stomach? Drape client at xiphoid process and symphsis publis to expose abdomen. Then make sure the client is comfortable in a supine position with knees flexed over a pillow or position client so that the arms are either folded across the chest or at sides to ensure abdominal relaxation. Where must you be to perform you assessment with the patient? Stand to the right side of client for exam.******* Have your client point to the areas that bothers them. use the two handed "sandwich" technique for ticklish patients Abdominal order of the assessment: Inspection What do you perform auscultation initially for abdominal assessment? performed second because palpation and percussion could alter bowel sounds. Abdominal inspection and landmarks Notice that the abdominal is broken down into 4 main areas: RLQ or Epigastric, Umbilical, and Hypogastric or Supraublic Abdominal Inspection: What are you observing? Observe the coloration of the skin. Note stiae (stretch marks) Inspect for scares Observe umbilical location: midline at later line What for peristaltic waves, normally not seen, although ay be seen in very thin people as slight ripple. Abdominal Inspection: Contour Normal abdomen is: Abnormal abdomen is: Auscultate for bowel sounds--the process place the diaphragm lightly on abdominal wall beginning in the RLQ. Note intensity, pitch and frequency of bowel sounds Listen for 1 min in an abdominal quadrant before concluding that bowel sounds are absent (5 mins total!!) Auscultate for Bowel Sounds Normal: a series of intermittent, soft clicking or gurgles heard at a rate of 5-30/min Hyperactive: >2-3 sounds or >30 loud, prolonged gurgles charactersitic of stomach growling (Borboygymi) Hypoactive: indicate decreased motility of the bowels (<5 sounds/ minute) Auscultate for Vascular Sounds place bell of stethoscope over abdominal aorta and renal, iliac, and femoral arteries to listen for bruits What are you listening for with you auscultate for vascular sounds in the stomach aortas? Friction rubs and/or bruits Aneurysm AAA Abdominal Percussion Process Percuss all four quadrants in a systematic manner. Begin percussion in the RLQ, moving upward to the RUQ crossing over the LUQ and moving down to the LLQ.
What sounds should you be hearing when you percuss the abdomen? Tympany: is the predominant sound heard because air is present in stomach and intestines. Dullness: is normally heard over organs such as the liver or a distended bladder. Note when tympany changes to dullness Percussion with ascites If you purcuss a person with fluid in the stomach--you should note that there will be a tympany sound where ever the fluid and is not and a dullness sound where the fluid is. That change in sound can indicate whether this person has ascites or is obese. Percussion of the Kidneys purpose: to assess for tenderness Position the client in sitting position with back facing the examiner. place left hand flat against costovertebral angle (CVA) over the 12th rib. Use ulner side of right fist to strike left hand. Normal: no tenderness is elicited. Examiner may sense a dull thud. Pain of CVA tenderness may suggest kidney infection or renal calcul ( stones). What is important to do before percussion of the abdominal? Ensure that your hands are warm to promote patient comfort and prevent muscle guarding. Palpate areas of tenderness last. Instruct client to take slow, deep breaths through the mouth. Begin with general pressure and gradually increase it . DO NOT PALPATE OVER AREAS WHERE BRUITS ARE AUSCULTATED! If client is ticklish, have the patient perform self-palpation with your hand over client's hand. Gradually remove the client's hand when ticklishness is gone. Observe client's face while performing palpation for changes in expression indicating pain or discomfort. Abdominal Palpation Light palpation: purpose is the identify tenderness, masses and muscular resistance. Use the pads of the finger to depress the abdominal wall 1CM. Avoid short, quick jabs. Lightly palpate all 4 quadrants in a systematic manner. Normal: no guarding; abdomen is soft Abnormal: involuntary guarding indicates peritoneal irritation. Abdominal Palpation Deep Palpation: the purpose is to assess for organ enlargement, masses, bulges or swelling. Use palmar surface of fingers, compress to a maximum depth or 5-8cm; bimanual for every large abdomens. Identify any massess and not location, size, shape, consistency, tenderness, pulsation, and degree of mobility. Abdominal Palpation of Liver Purpose is to note consistency and tenderness. Bimanual: stand at client's right side and place left hand under client's back at level 11th or 12th ribs. Lay right hand parallel to right costal margin. Ask patient to inhale then compress upward and inward with your fingers. Normal: liver is usually not palpable, although it may be felt in some thin clients. If lower edge is felt, it should be firm, smooth and even. Mild tenderness may be normal Abnormal: hard first liver may indicate cancer. Nodularity may occur with tumors, cancer late cirrhosis or syphilis. Tenderness may be from vascular engorgement (CHF) or hepatitis. Abdominal Palpation: palpate the spleen: Normal: spleen is seldom palpable at left costal margin Abnormal: palpable spleen suggest enlargement. notes: an enlarged spleen may rupture on palpation. Palpation of the Urinary Bladder Purpose is the palpate for a distended bladder. Using deep palpation, begin at smphysis pubis and move upward and outward to estimate bladder borders. Urinary Bladder Examination Outcome Normal: empty bladder not palpable. Abnormal: distended bladder is palpated as a smooth, round and somewhat firm mass. Moderately full bladder is palpable above symphysis pubis Full bladder is palpated above the symphysis pubis and may be close to umbilicus. How do you palpate the inguinal lymph nodes place client in supine position with knees sight flexed. Using your 2nd, 3rd, and 4th fingers apply firm pressure and palpate with a rotary motion in the right and left inguinal area. Normal: nonpalpable Abnormal: tender, enlarged lymph nodes--indicates infection and can be moveable. Larger than 1cm, hard non-movable-MAY BE SERIOUS! Apley's Law: please define the law The recurrent abdominal pain is experienced the greater the distance from umbilicus, the greater the chance of organic etiology. Special Abdominal Tests Rebound tenderness: have the patient in the supine position. Apply several seconds of firm pressure to the abdomen, with had at 90 degrees to abdomen and the fingers extended. Quickly release the pressure. Normal: pain is not elicited Abnormal: as abdominal wall returns it normal position, patient complains of pain at pressure (direct rebound tenderness) or at another site (referred rebound tenderness). May indicate peritoneal irritation --> sharp pain in area of inflammation Ilipsoas Muscle test R/O appendicitis Tests for Appendicitis Rebound tenderness When is the best time to measure abdominal girt? Measure abdominal girth at same time each day. Ideally in the morning just after voiding. Ideal position is patient standing. Otherwise client should be in supine position. Place take measure behind client and measure and umbilicus. What is happening the abdomen of the older adult Esophageal emptying is delayed increased risk for aspiration Abdominal musculature loses much of its tone Increased fat deposition in abdominal area. Gastric acid decreases which may interfere with vitamin B12 absorption Mucosal lining of GI tract becomes less elastic, and changes in gastric motility result in alterations in digestion and absorption. Blood flow through the liver is decreased by 55% which can impair drug metabolism. Increased complains of gas or constipation Increased incidence of GI malignancy. Intestines subject to ischemia related to atherosclerosis. What is the order of assessment technique when assessing the abdomen?Assessing your patient's abdomen can provide critical information about his internal organs. Always follow this sequence: inspection, auscultation, percussion, and palpation.
How do you assess the abdomen quizlet?Rationale: The correct order for abdominal assessment is inspection, auscultation, percussion, palpation. Palpation is the last step in abdominal assessment. Auscultation follows assessment because percussion and palpation can alter the frequency and intensity of bowel sounds.
What are the steps of an abdominal assessment?The abdominal examination consists of four basic components: inspection, palpation, percussion, and auscultation. It is important to begin with the general examination of the abdomen with the patient in a completely supine position.
What assessment technique should be used to measure abdominal girth quizlet?Explanation: The umbilicus should be used as the starting point for measuring abdominal girth, especially when ascites is present. Measure the girth at the same time each day, ideally after the client voids in the morning. The ideal position is for the client to stand.
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