Weber Ch 21 Abdominal

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cswett
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Weber Ch 21 Abdominal
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2011-10-17 10:16:15
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Weber 21 Abdominal
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Weber Ch 21 Abdominal
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  1. GI Anatomy & Physiology
    • • Abdominal cavity: largest body cavity
    • –Stomach, small & large intestines, liver, gallbladder, pancreas, spleen, kidneys, ureters, bladder, adrenal glands, major vessels + female reproductive
    • • Borders
    • • Peritoneal cavity (parietal & visceral)
    • • Esophagus: outside but part of GI system,pH 6-8
  2. Stomach
    • • Hollow, flask-shaped,muscular organ directly below diaphragm LUQ
    • • Esophageal contentsenter stomach and mixwith digestive enzymesand hydrochloric acid
    • • Gastric acid continuesbreakdown ofcarbohydrates that beganin mouth pH 2-4
  3. Small Intestine
    • • Longest section 21 ft.
    • • Ingested food is mixed,digested, and absorbed
    • • Three segments
    • – Duodenum
    • – Jejunum
    • – Ileum & ileocecal valve
  4. Large Intestine (Colon) &Rectum
    • • Cecum, appendix, colon, rectum, and anal canal
    • • Three parts:
    • – Ascending
    • – Transverse
    • – Descending
    • • Rectum: sigmoid colon to pelvic floor, ends at anus
    • • Absorbs water andelectrolytes
    • – Feces formed in large intestine and held until defecation
  5. Accessory Organs: Liver
    • • Largest organ
    • • RUQ 5th ICS to below costal margin - goes down about 3 ICS's but should not be below ribcage
    • • Right & left lobes
    • • Multi Functions:
  6. Accessory Organs: Gallbladder
    • • Pear-shaped sacinferior surface of liver• Concentrates/storesbile
    • • Cystic duct joins hepatic duct, forming common bile duct
    • —drains bile into duodenum
    • Fat, Forty, Flatulent, Furtle
  7. Accessory Organs: Pancreas
    • • Left upper quadrant
    • • Endocrine and exocrine functions
    • – Produces endocrine enzymes (insulin,glucagon, gastrin)
    • —carbohydrate metabolism
    • – Exocrine secretions contain bicarbonate and pancreatic enzymes,breaks down proteins, fats, and carbohydrates
  8. Accessory Organs: Spleen
    • • Part of lymphatic system; upper left abdominal cavity (LUQ)
    • • Functions:
    • – Storage of 1-2% of erythrocytes and platelets -Macrophages remove old/agglutinated erythrocytes and platelets
    • – Activates B and Tlymphocytes
    • – Produces erythrocytes during bone marrow depression
  9. Genitourinary System
    • –Kidneys & Bladder Kidneys, ureters, bladder, & urethra
    • KUB - kidneys, urinary & bladder test
    • - remove water soluble wastes Kidneys location
    • – posterior abdominal cavity T12
    • – L3 partially protected by ribs & fat/fascia
    • Kidney Functions:
  10. Abdominal Vascular Structures:
    • Abdominal Aorta
    • Renal Arteries
    • Right & Left Iliac Arteries
    • Listen for bruits(aorta, renal, iliac,femoral arteries)
    • Venous System
  11. GI/Abdominal Health History
    • • Present History of Chief Complaint
    • • Past Medical History
    • • Family History
    • • Lifestyle & Health Practices
  12. GI PROBLEM-BASED HISTORY“OLD CARTS”
    • • PAIN
    • • NAUSEA & VOMITING
    • • INDIGESTION
    • • ABDOMINAL DISTENTION
    • • CHANGE IN APPETITE
    • • CHANGE IN BOWEL HABITS
    • • JAUNDICE/YELLOW DISCOLORATION OF SKIN & EYES
  13. History of Chief Complaint
    • • Abdominal PAIN
    • – “OLDCARTS”

    • – Onset pain
    • - When did you first feel pain?
    • What activity were you doing?

    • – Location pain
    • - Has pain changed location since started?
    • Felt elsewhere?

    • – Duration pain
    • - Constant or intermittent?

    • – Characteristics pain
    • - Burning, gnawing, colicky

    • – Aggravating/alleviating factors
    • –What makes it worse?
    • What relieves pain?
    • Any particular position?

    – Related or associated symptoms (diarrhea/constip.)

    – Treatments tried (antacids, heat, rest)

    – Severity (0 to 10 scale)
  14. Nausea and Vomiting
    • • Nausea or vomiting for how long? Frequency?
    • • How much do you vomit? What does it look like?Contain blood? Have an odor?
    • • Females: Could you be pregnant?
    • • Nausea without vomiting?
    • • Foods eaten in last 24 hours? Where? How longafter eating did you vomit? Anyone else had these symptoms over same time period?
    • • Other symptoms: Pain? Constipation? Diarrhea?Change in stool/urine color? Fever or chills?
  15. Indigestion
    • • Indigestion/heartburn for how long? Where?Stomach? Chest? How often?
    • • What makes it worse? Change of position?
    • • What relieves the pain? Antacids or acidblockers?
    • • Other symptoms: Radiating pain? Sweating?Lightheadedness?
  16. Abdominal Distention
    • • How long? Come and go? Related toeating? What relieves it?
    • • Other symptoms: Vomiting? Loss ofappetite? Weight loss? Change in bowelhabits? Shortness of breath? Pain?
    • • 7 “F” of abd. distention: fat/obese, fetus/pregnant, fluid/ascites (fluid in abdominal cavity), flatulence/gas, feces/constipation, fibroid tumor, fatal tumor/malignancy.
  17. Change in Bowel Habits
    • • Describe change: Frequency; consistencyof feces? First notice change? How long?Changed diet? Changed activity level?What does stool look like—bloody, mucoid,fatty, watery?
    • • Other symptoms: Increased gas, pain,fever, nausea, vomiting, abdominalcramping, diarrhea? Time of day when occurs—after eating or at night?
  18. Yellow Discoloration of Eyesor Skin (Jaundice)
    • • First noticed? More noticeable?
    • • Associated with abdominal pain, loss ofappetite, nausea, vomiting, fever?
    • • Blood transfusion/tattoos in past year?Using IV drugs? Eat raw shellfish, e.g.,oysters? Traveled abroad in last year? Where? Drink unclean water?
    • • Has color of your urine or stools changed?
  19. Health History:Past Health Status
    • • Any chronic diseases that affect your GI or urinary systems? Describe.
    • • Have had prior problems with abdomen ordigestive system? Esophagus? Stomach? Intestines? Liver? Gallbladder? Pancreas?Spleen? Describe
    • • Medications? What and how often?(esp. ASA, iron, & laxatives)
    • • Viral hepatitis A, B or C ?
    • • Abdominal surgery or trauma?
  20. Health History: Family History
    • • Family history - diseases of GI system
    • • Gastroesophageal refluxdisease /GERD
    • • Peptic ulcer disease (PUD)
    • • Stomach/colon cancer
    • • Kidney/bladder cancer
    • • Pancreatic cancer
  21. LIFESTYLE & HEALTH PRACTICES
    • • Alcohol (how much & type)
    • • Typical foods & fluids, esp. caffeine, tea, & sugary soft drinks
    • • Exercise program – peristalsis
    • • Stresses in life can cause GI upset
    • • How does GI disorder affect lifestyle?
  22. History of GI CA Risk Factors
    • Age: risk increases with age
    • Gender: men > greater than women
    • Race:African Americans
    • Asian/Pacific Islanders
    • Whites
    • Tobacco/smoking
    • Alcohol: long-term use increases risk (used together with tobacco raises risk more than using alone)
    • Genetics
    • Diet
  23. GI/ABD. Physical Exam Differences
    • • Key assessment points:
    • –Observe and inspect abdominal skin and overall contour and symmetry
    • –Auscultate AFTER inspection and BEFORE percussion
    • –Palpate last
    • LOOK
    • LISTEN - dont push down
    • TOUCH
  24. GI Inspection Techniques
    • • General appearance – observe generalbehavior and position
    • • Abdomen - Inspect for skin color, surface characteristics, contour, umbilicus
    • • Inspect for surface movements– Peristalsis not visible—midline pulsation if thin– Client raises head—rectus abdominis muscleprominent with midline bulge; no hernias– Aortic pulsations in epigastric area
    • • If ostomy—inspect stoma– Red/moist, area where bag is attached toskin; well healed, without lesions/excoriations
  25. Auscultate Abdomen
    • • Auscultate for bowel sounds diaphragm of stethoscope
    • – Sounds every 5-15 seconds,last 1 to several seconds
    • – High pitched gurgles/clicks
    • – RUQ, LUQ, LLQ & RLQ
    • – Borborygmi (gasous sounds)
    • • Auscultate for vascular sounds– Stethoscope (bell) over aorta,renal, iliac, & femoral arteries for bruits– Bell—over epigastric area/around umbilicus for venous hum
  26. GI PERCUSSION
    • • Percuss abdomen for tones
    • – Routine “3” to cover all 4 quadrants
    • – Tympany heard where gas
    • – Dullness where bladder full, or underlying mass– Percuss:
    • Liver
    • Spleen
    • Kidneys (blunt)
  27. Light Palpation
    • • Palpate abdomen (light,1-2 cm) for tenderness,muscle tone, and surface characteristics
    • – All quadrants
    • – Pads of fingertips
    • – No tenderness, muscles should be relaxed
    • – If abdominal pain, palpate area of pain last
  28. Deep Palpation
    • • Palpate abdomen (deep,4-6cm) for tenderness,masses, and aorticpulsation
    • – All quadrants
    • —distal flat portion of finger pads,bimanual technique
    • – Observe for facial grimaces
    • – Breathe slowly via mouth
    • – If pain, palpate area last
    • – Aorta
    • – Borders of R. abdominus muscle, sacral promontory, feces in ascending or descending colon felt
  29. Abdominal Palpation
    • • Palpate around umbilicus for bulges, nodules, and umbilica lring
    • – Ring should be round with no irregularities or bulges
    • – Umbilicus—inverted or slightly everted
    • • Palpate liver, gallbladder (Murphy’s sign) and spleen
    • • Palpate kidneys
    • • Elicit abdominal reflexes for presence
  30. Special Abdominal Tests
    • Additional assessment
    • techniques for special cases
    • – Percuss kidneys forCVA tenderness
    • – Assess abdomenfor fluid, if fluid is suspected
    • • Shifting dullness
    • • Fluid wave
    • • Ballottement
  31. Special Tests: Appendicitis
    • • Assess abdomen for pain
    • • If abdominal pain, test for rebound tenderness
    • • McBurney’s sign (looking at appendix), Iliopsoas & obturator muscle tests
  32. Elderly GI Variations:
    • Arteriosclerosis (decreased blood flow)—decreased absorption from small intestine
    • Slowed motility & weak muscles— decreased transit time through intestines (constipation)
    • – Esophagus (decreased motility/pressure),increased regurgitation (GERD)
    • – Gastric mucosa (degenerates)- reduction in parietal cells that secrete intrinsic factor (interferes with vitamin B12 absorption) Bariatric procedures (stomach staple) will need to take supplements due to loss of absortion cells
    • – Large intestine (Bacterial flora [less biologicallyactive]—food intolerance and impaired digestion)
    • – Liver size decreases after age 50 so less metabolism of drugs & ETOH

    • Normal and abnormal findings
    • – Increased fat deposits over abdomen/less subcutaneous fat over extremities
    • – Abdomen soft (loss of abdominal muscletone)—organ palpation easier
    • – Note distention/concavity associated with general wasting signs or anteroposterior rib expansion
  33. COMMON GI/ABD. PROBLEMS
    • GERD - gastric reflux - affects younger rather than older clients
    • • Hernia
    • • Peptic Ulcer Disease - H.pylori bacteria, stress
    • – Gastric ulcer - burning eligastric pain 1-2 hrs after eating - antacids help
    • – Duodenal ulcer -Chrones disease - high stress jobs (type A personalities) - pain 2-4 hours after eathing
    • • Diverticulitis - middle to older - mostly female - outpouching of GI tract
    • • Cholecystitis -
    • • Hepatitis - viral inflamation of liver - pain, jaundice, malaise
    • • Cirrhosis - end stage disease of liver - drugs or alcohol - fatty liver is precursor
  34. NUTRITIONAL ASSESSMENT
    • • Basal metabolic rate = 0ptimal nutritional status/ base energy requirements (calorie intake=energy needs)
    • • Undernutrition = calorie intake less than energy needs so weight loss
    • Overnutrition = calorie intake exceeds energy needs so weight gain
  35. BMI
    IBW
    • BMI = Body Mass Index
    • Wt. In Kg
    • Ht. In meters 2 (squared)
    • < 18.5 underwt.
    • 18.5-24.9 normal
    • 25-29.9 overwt.
    • 30-34.9 mild obese
    • 35-39.9 moderate obese
    • > 40 extremely obese
    • • IBW = Ideal Body Weight
    • Male 106 lbs for 5 ft. then 6 lbs for each inch
    • Female 100 lbs for 5 ft. then 5 lbs for each inch
    • Actual wt x 100 = % IBW
    • < 70% severe malnut.IBW
  36. NUTRITIONAL EXAM
    • Triceps Skinfold
    • ThicknessMale= 12.5 mm
    • Female= 16.5 mm
  37. HYDRATION STATUS:
    • • I & O
    • • Weight esp. gain of > 6-10 lbs in 1 wk.
    • • Skin turgor - elderly - tent on sternum
    • • Pitting edema
    • • Whether skin dry & flaky
    • • + JVD at 45 degrees - should not see jugular pulse on neck unless really skinny
    • • Tongue dry with furrows
    • • Eyeballs soft & sunken with dark circles
    • • Lung sounds with crackles
    • • + Orthostatic BP - descrease of 20 mm Hg when you change position

    600 ml = insensible loss - I & O should balance within 600 ml
  38. Elderly Nutritional Variations
    • • Decreased taste sensation so prone to anorexia
    • • Decreased intestinal absorption
    • • Prone to dehydration esp. in nursing homes
    • • Chewing & swallowing problems
    • • Skinfold measurements inaccurate (fat shifts from upper body to waist)
    • • Evaluate for food & drug interactions
    • • Social problems lead to poor nutrition
    • • Don’t worry about high cholesterol > 70 yrs. old if no other cardiovascular risk factors

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