Weber Ch 21 Abdominal
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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
- • 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
- • Longest section 21 ft.
- • Ingested food is mixed,digested, and absorbed
- • Three segments
- – Duodenum
- – Jejunum
- – Ileum & ileocecal valve
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
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:
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
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
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
- –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:
Abdominal Vascular Structures:
- Abdominal Aorta
- Renal Arteries
- Right & Left Iliac Arteries
- Listen for bruits(aorta, renal, iliac,femoral arteries)
- Venous System
GI/Abdominal Health History
- • Present History of Chief Complaint
- • Past Medical History
- • Family History
- • Lifestyle & Health Practices
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
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
– Related or associated symptoms
- – Aggravating/alleviating factors
- –What makes it worse?
- What relieves pain?
- Any particular position?
– Treatments tried
(antacids, heat, rest)
(0 to 10 scale)
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?
- • 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?
- • 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.
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?
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?
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?
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
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?
History of GI CA Risk Factors
- Age: risk increases with age
- Gender: men > greater than women
- Race:African Americans
- Asian/Pacific Islanders
- Alcohol: long-term use increases risk (used together with tobacco raises risk more than using alone)
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
- LISTEN - dont push down
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
- • 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
- • Percuss abdomen for tones
- – Routine “3” to cover all 4 quadrants
- – Tympany heard where gas
- – Dullness where bladder full, or underlying mass– Percuss:
- Kidneys (blunt)
- • 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
- • 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
- • 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
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
Special Tests: Appendicitis
- • Assess abdomen for pain
- • If abdominal pain, test for rebound tenderness
- • McBurney’s sign (looking at appendix), Iliopsoas & obturator muscle tests
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
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
- • 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
- 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
- Triceps Skinfold
- ThicknessMale= 12.5 mm
- Female= 16.5 mm
- • 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
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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