N112

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Author:
LaurenFleming
ID:
85654
Filename:
N112
Updated:
2011-05-13 14:55:12
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Abdominal Assessment
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exam 2
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  1. Order of Abdominal Assessment???
    •Inspection

    • •Auscultation (performed second
    • because palpation and percussion can alter bowel sounds).

    •Percussion

    •Palpation
  2. Striae
    old, silvery, white stretch marks from past pregnancies or weight gain
  3. Scaphoid abdomen
    occurs with malnourishment or dehydration
  4. Hernia
    Protrusion of abdominal viscera through abnormal opening in muscle wall
  5. Caput Medusae
    Engorged superficial capillaries of abdomen
  6. •Inspect Contour, Symmetry, Movement:
    • •Look across abdomen at eye level. Abdomen is flat, rounded,
    • or scaphoid. Should be evenly rounded.
  7. Abnormal Abdomens
    Scaphoid abdomen, protuberant abdomen, abdominal distention
  8. Observe aortic pulsations
    • a slight pulsation may be visible in the epigastrium and extends full length in thin
    • people.
  9. Watch for peristaltic waves
    normally not seen, although may be seen in very thin people as slight ripples.
  10. What quadrant do you begin the abdominal assessment??
    RLQ
  11. How long do you listen to bowel sounds before concluding they are absent???
    5 min in an abdominal quadrant
  12. After starting on the RLQ, where do you move the diaphragm next??
    •Move diaphragm to RUQ, LUQ, LLQ.
  13. Normal Bowel sounds
    a series of intermittent, soft clicks and gurgles heard at a rate of 5 to 30/min.
  14. Hyperactive Bowel sounds
    loud, prolonged gurgles, high pitched

    *increased mobility, diarrhea
  15. Hypoactive Bowel sounds
    •indicate decreased motility of bowels.
  16. Borborygmi
    The sound that gas makes as it moves through the intestines. It can occur when you're hungry, but it can also happen after meals. It's often called "stomach growling" or "stomach rumbling." Borborygmi is normal and happens to everyone from time to time.
  17. Where do you listen to bruits on the abdomen??
    abdominal aorta and renal, iliac, and femoral arteries to listen for bruits. Especially important if client has HTN or if arterial insufficiency is suspected.
  18. Are bruits normally heard??
    NO
  19. If bruit is present it represents
    aneurysm or arterial stenosis.
  20. Where do you listen to a venous hum
    in the epigastric and umbilical areas using the bell of the stethoscope

    NOT NORMALLY heard
  21. Accentuated venous hum heard in epigastric or umbilical areas suggests???
    obstructed portal circulation.
  22. Auscultate for friction rub over
    •liver and spleen by listening over the right and left lower rib cage with the diaphragm of stethoscope.

    •Normal: no friction rub auscultated.
  23. Friction rubs are??
    abnormal, high-pitched, rough, grating sounds produced when the large surface area of the liver or spleen rubs the peritoneum.

    **Heard in association with respiration. Indicate inflammation or tumors.
  24. Tympany
    is predominant sound heard because air is present in stomach and intestines.
  25. Dullness
    is normally heard over organs such as the liver or a distended bladder. Note when tympany changes to dullness.
  26. Stages of liver Damage
    fatty liver, liver fibrosis, Cirrhosis
  27. Ascites
    Fluid in the abdomen
  28. Purpose of Blunt Percussion of the kidneys
    •to assess for tenderness in difficult-to-palpate structures.
  29. How do you perform blunt percussion of the kidneys
    •Position client in sitting position with back to examiner.

    •Place left hand flat against costovertebral angle (CVA) over the twelfth rib. Use ulnar side of right fist to strike left hand.
  30. What is Normal with Blunt percussion of the Kidneys??
    no tenderness is elicited. The examiner may sense only a dull thud.

    **Pain or tenderness over CVA may suggest kidney infection or renal calculi (stones).
  31. What do you do if the client is ticklish??
    •If client ticklish, have client 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
  32. What is the purpose of light palpation
    to identify areas of tenderness, masses and muscular resistance.
  33. How to Perform Light palpation
    •With hands and forearm on a horizontal plane, use the pads of the approximated fingers to depress the abdominal wall 1 cm.

    • **Avoid short, quick jabs. Lightly palpate all four quadrants in a systematic manner by gently
    • lifting fingers and moving to next area.
  34. What is Normal is Light Palpation??
    •Normal: no guarding; abdomen is soft

    •Abnormal: involuntary guarding indicates peritoneal irritation.
  35. Purpose of Deep Palpation
    to assess for organ enlargement, masses, bulges, or swelling
  36. How to Assess Deep Palpation
    •Use palmar surface of fingers, compress to a maximum depth of 5 to 6 cm in RLQ.

    Perform bimanual palpation if resistance is encountered, client is obese, or to assess deeper structures.

    Identify any masses and note location, size, shape, consistency, tenderness, pulsation, and degree of mobility. Continue palpation of other quadrants.
  37. What is Normal for Deep Palpation
    •Normal: only aorta and edge of liver are palpable.

    **No palpable organ enlargement, nor masses, bulges, or swelling.
  38. What are the Two types of Deep palpation
    One-Hand Method

    Bimanual Method
  39. What is the purpose of Palpating the Liver
    to note consistency and tenderness.
  40. Bimanual Palpation of the Liver
    •Bimanual: stand at client’s right side and place left hand under client’s back at the level of 11th to 12th ribs.

    • *Lay right hand parallel to right costal margin
    • (fingertips should point toward client’s head). Ask client to inhale, then compress upward and inward with your fingers.
  41. What is Normal with Liver Palpation
    • 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.
  42. What is Abnormal with Liver Palpation
    hard, firm liver may indicate cancer. Nodularity may occur with tumors, cancer, late cirrhosis, or syphilis. Tenderness may be from vascular engorgement (CHF) or hepatitis
  43. What is Normal with Spleen Palpation
    spleen is seldom palpable at left costal margin; rarely, the tip is palpable in the presence of a low, flat diaphragm as in emphysema.
  44. What is Abnormal with Spleen Palpation
    palpable spleen suggests enlargement.

    Palpate spleen gently as an enlarged spleen may rupture.
  45. Purpose of palpating the Bladder
    to palpate for a distended bladder
  46. How To Palpate the Bladder
    Using deep palpation, begin at symphysis pubis, and move upward and outward to estimate bladder borders
  47. What is Normal with Bladder Palpation
    empty bladder not palpable
  48. What is Abnormal with Bladder Palpation
    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 symphysis pubis and may be close to umbilicus.
  49. How to Palpate Inguinal Nodes
    •Place client in supine position, with knees slightly flexed.

    • *Using finger pads of 2nd, 3rd, & 4th fingers, apply firm pressure and palpate with a rotary
    • motion in the right inguinal area.

    • Palpate for lymph nodes in left inguinal
    • area.
  50. Normal with Palpation of the Inguinal Nodes
    • •Normal: small, movable, nontender nodes less than
    • 1 cm in diameter
  51. Abnormal with Palpation of the Inguinal Nodes
    •Abnormal: greater than 1 cm in diameter nonmovable, tender lymph nodes. Localized or systemic infections, cancer or lymphomas.
  52. How to Assess for Rebound Tenderness
    •Client is supine. Apply several seconds of firm pressure to the abdomen, with hand at a 90 degree angle (perpendicular to abdomen) and the fingers extended. Quickly release the pressure.
  53. Normal for Rebound Tenderness
    pain is not elicited
  54. Abnormal for Rebound Tenderness
    as abdominal wall returns to its normal position, client complains of pain at pressure site (direct rebound tenderness) or at another site (referred rebound tenderness). May indicate peritoneal irritation--> sharp pain in area of inflammation.
  55. Appendicitis
    pain in RLQ at McBurney’s point
  56. mcBurney’s point
    - 1/3 the distance of the interior superior spine to the umbilicus
  57. When do you want to measure Abdominal Girth??
    •measure abdominal girth in all clients with abdominal distention.

    •Measure abdominal girth at same time each day. Ideally in morning just after voiding.
  58. How do you Position a client for Abdominal Girth
    • •Ideal position for client is standing; otherwise client should be in supine position. Head may be
    • slightly elevated for orthopneic clients. Client should be in same position for all measurements.

    •Use a disposable or easily cleaned tape measure.
  59. How to Measure Abdominal Girth
    •Place tape measure behind client and measure at umbilicus.

    •Record measurement in inches or centimeters.

    Take all future measurements as same location. Mark site with a ballpoint pen
  60. Things that affect the Older Adult
    •Esophageal emptying is delayed increasing risk for aspiration

    •Abdominal musculature loses much of its tone.

    •Increased fat deposition in abdominal area.

    •Gastric acid decreases which may interfere with vitamin B 12 absorption

    •Increased complaints of gas or constipation.

    •Increased incidence of gastrointestinal malignancy.

    •Intestines subject to ischemia related to atherosclerosis.
  61. In the Older Adult Mucosal lining of gastrointestinal tract becomes
    less elastic, and changes in gastric motility result in alterations in digestion and absorption.
  62. Blood flow through the liver is decreased by
    55 % which can impair drug metabolism

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