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1. What information would the nurse gather when taking a history prior to abdominal assessment?
- Location/character/onset/frequency/aggravating factors/type of pain
- observe movement & position
- BM habits and character
- any surgeries/traumas
- recent weight change, nausea, vomiting, cramping
- difficulty swallowing, belching, flatulence, black or tarry stools, heartburn, diarrhea or constipation
- taking antiinflammatory meds like aspirin, ibuprofen, steroids, or on antibiotics
- ask to locate tender moments before exam
- family hx of cancer, kidney disease, alcoholism, hypertension or heart disease
- is female pt pregnant/last menstruation
- alcohol intake
- review hx for exposure to hep B etc
2. What would the nurse be looking for during inspection of the abdomen?
- Look at posture for signs of splinting or restlessness.
- Inspect for abnormal shadows, abdominal contour.
- Contour: Flat, Scaphoid, Rounded, Protuberant [nutritional state], intestinal gas, tumor or fluid causes distention. When distention is generalized entire abdomen protrudes. When caused by gas flanks (sides) do not bulge. If fluid is the cause flanks bulge, when pt on side and protuberance forms on dependent side fluid is the cause.
- Symmetry: No budges, masses (hernia); if asymmetrical indicates underlying pathological condition.
- Umbilicus: Midline, inverted, no discoloration, inflammation, protrusions (caused by masses), should be flat or concave. Everted (pouched out) indicates distention. Hernias cause upward protrusion. There should be no discharge.
- Skin: smooth, even, possible striae (stretch marks; recent=pink or blue), scars, artificial openings (for previous drains or surgery), bruising, needle marks, jaundice, cyanosis, ascites (shiny skin that is taut)
- Pulsation: may see aorta pulsate
- Hair Distribution: pubic hair male (diamond shape) female (inverted triangle)
- Demeanor: benign facial expression, relaxed
3. What are the landmarks of the abdomen used to identify findings and perform assessment?
- Xiphoid process: the upper boundary of anterior abdomen
- Symphysis pubis: mark the lower boundary
- Divided in 4 quadrants: RUQ, LUQ, RLQ, LLQ
- Posteriorly: lower ribs and heavy back muscles protect kidneys, located from T12-L3 vertebrae
4. What is the order followed when assessing the abdomen?
- IAP=Inspection, Auscultation, Palpation; auscultate before percussion and palpation to not alter frequency and character of bowel sounds
5. What are normal bowel sounds?
high pitched, soft gurgling or clicking sound, are irregular, occur 5-35 times per minute, last ½ second to several seconds; normally takes 5-20 seconds to hear them
6. How long would the nurse listen to bowel sounds?
5 mins of continuous listening before saying bowel sounds are absent
7. What would be considered abnormal bowel sounds?
- Vascular sounds like bruits indicate narrowing of major blood vessels and disruption of blood flow.
- May reveal aneurysms or stenotic vessels. Use bell of stethoscope in epigastric region and each quadrant.
- If heard report immediately.
- May also be associated with peritonitis or paralytic ileus.
8. What is the nurse assessing during palpation of the abdomen?
Detects abdominal tenderness, distention and masses. Nurse is also assessing specific organs.
9. How would the nurse palpate for aortic pulsation?
Using the thumb and forefinger of one hand to deeply palpate into the upper abdomen just left of the midline to assess.
10. When would the nurse assess for bladder distention? How would this assessment be performed?
If patient has been unable to void or has been incontinent or if an indwelling urinary catheter is not draining well. Use light palpation.
What are the various purposes for catheterization of the
- 1) to relieve discomfort r/t bladder distension (e.g. after surgery or r/t a medical condition)
- 2) to obtain a sterile urine specimen
- 3) to measure residual urine amounts
- 4) to provide continuous urinary bladder drainage (decompresses the bladder)for example during a long surgery to prevent injury or complications related to surgeon nipping the bladder during the procedure.
- 5) to provide continuous bladder irrigation
- 6) to monitor urine output accurately in seriously ill patients (e.g. ICU)
- 7) to promote repair to urinary structures after surgery
How does the nurse irrigate a Foley catheter?
- Wash hands, apply non sterile gloves. Using aseptic technique, pour sterile irrigating solution into sterile container. Cleanse around tubing connection with alcohol or beta dine, disconnect catheter for thing. Cover tube w/ sterile cap. Put sterile drainage basin under catheter.
- Connect large volume syringe to the cath. Any irrigate catheter using prescribed amount of sterile irritant. Remove syringe and place end of cath. over drainage basin. Allow returning fluid to drain into basin. Repeat irrigation until fluid is clear, or according to physicians directives.
- Disinfect the distal end of catheter and end of drainage tube. Reconnect the catheter and tubing. Remove gloves and wash hands. Document the type of irrigating solon, color, and character of returning fluid.
How does the nurse perform a sterile catheterization of a female mannequin, using a straight and indwelling catheter?
- Separate labia majora and minor, so urethral meatus is visualized. This hand will maintain separation of the labia until procedure is finished. Cleanse bottom w/ betadine saturated cotton balls. Ask pt if they have an allergy to betadine. Clean the area (outside, outside, inside), and with a downward motion from anterior to post (front to back).
- Introduce well lubricated catheter 2-3 inches into urethral meatus using sterile technique. Observe for urine to flow through catheter. Advance 1 to 2 inch more. Inflate ballon, using provided syringe filled w/ 10ml sterile water. Collect specimen as ordered.
How does the nurse perform a sterile catheterization of a male mannequin, using a straight and indwelling catheter?
- Wash off the glans penis around urinary meatus w. betadine cotton ball. Keep foreskin retracted w/ one hands. Grasping the shaft of the penis, elevate it, applying gentile traction to the penis while the catheter is inserted, Insert catheter into urethra, advancing it approx. 6-10 inches until urine flows.
- If resistance is felt at the external sphincter, slightly increase the traction on the penis, apply steady pressure, and ask the pt to strain slightly as if passing urine. This helps the sphincter to relax. When urine begins to flow, advance the all the way. Replace, or reposition the foreskin.
- Tape foley catheter to the leg. Allow some slack of tubing to accommodate movement. Keep tubing over the pts leg. Some pts may like a damp washcloth to remove the betadine form the labia. Avoid the use of powders and sprays when cleaning the perineum. These can encrust and cause soreness.