Abdominal Assessment

Cirrhosis

A chronic, degenerative disease of the liver that interferes with normal liver function. Assess for: • Fatigue • Significant change in weight • GI symptoms, such as anorexia and vomiting • Abdominal pain and liver tenderness (both of which may be ignored by the patient) The first sign may present before the onset of symptoms when routine laboratory tests, presurgical evaluations, or life and health insurance assessments show abnormalities. These tests could indicate abnormal liver function or thrombocytopenia, requiring a more thorough diagnostic workup. The development of late signs of advanced cirrhosis (also called "end-stage liver failure") usually cause the patient to seek medical treatment. GI bleeding, jaundice, ascites, and spontaneous bruising indicate poor liver function and complications of cirrhosis. Thoroughly assess the patient with liver dysfunction or failure because it affects every body system. The clinical picture and course vary from patient to patient depending on the severity of the disease. Assess for: • Obvious yellowing of the skin (jaundice) and sclerae (icterus) • Dry skin • Rashes • Purpuric lesions, such as petechiae (round, pinpoint, red-purple lesions) or ecchymoses (large purple, blue, or yellow bruises) • Warm and bright red palms of the hands (palmar erythema) • Vascular lesions with a red center and radiating branches, known as "spider angiomas" (telangiectases, spider nevi, or vascular spiders), on the nose, cheeks, upper thorax, and shoulders • Ascites (abdominal fluid) • Peripheral dependent edema of the extremities and sacrum • Vitamin deficiency (especially fat-soluble vitamins A, D, E, and K) -Observe vomitus and stool for blood. This may be indicated by frank blood in the excrement or by a positive fecal occult blood test (FOBT) (Hema-Check, Hematest). -Gastritis, stomach ulceration, or oozing esophageal varices may be responsible for the blood in the stool. -Note the presence of fetor hepaticus, which is the distinctive breath odor of chronic liver disease and hepatic encephalopathy and is characterized by a fruity or musty odor. -Amenorrhea (no menstrual period) may occur in women, and men may exhibit testicular atrophy, gynecomastia (enlarged breasts), and impotence as a result of inactive hormones. -Patients with problems of the hematologic system caused by hepatic failure may have bruising and petechiae (small, purplish hemorrhagic spots on the skin). -Continually assess the patient's neurologic function. Subtle changes in mental status and personality often progress to coma—a late complication of encephalopathy. -Monitor for asterixis—a coarse tremor characterized by rapid, nonrhythmic extensions and flexions in the wrists and fingers (hand-flapping).

based on the client's assessment, what condition would the nurse suspect?

Appendicitis Pain is usually in the right lower quadrant when experiencing an appendicitis. Patient also had a appedectomy in the past. Liver failure Assessment did not demonstrate fluid in abdomen, jaundice, or other signs of liver failure. Cholecystitis Characterized by right upper quadrant pain, nausea, and vomiting after eating. Ureteral colic Characterized by flank pain that wraps around to the groin. Nausea and vomiting may be present.

The nurse questions the client if there are any foods she cannot eat. The client reports that she doesn't tolerate spicy foods. What questions should the nurse ask next? (Select all that apply.)

Can you identify which spicy foods cause a problem? This information will be helpful in planning interventions for meal preparation. How often do you eat spicy foods? Other information is more useful in assessing the client's inability to tolerate spicy foods. What happens when you eat spicy foods? The client's response is the most useful regarding the nature of her inability to eat spicy foods and any underlying problems. Does anyone in your family have problems with spicy food? This information is not helpful in assessing the client's inability to eat spicy foods. Why do you think spicy foods are a problem? This question not help determine food intolerances.

The nurse completes an admission assessment. The client tells the nurse that she feels like she needs to vomit. The nurse helps the client to sit up at the side of the bed and provides her with an emesis basin. The client vomits into the emesis basin and then remains sitting on the side of the bed, stating that she may need to throw up again. Which assessment should the nurse complete first?

Check the pulse. Another assessment should be completed before assessing the client's pulse rate, which might be elevated secondary to vomiting. Listen to bowel sounds. Another assessment should be completed before assessing for bowel sounds. Observe the color of the emesis (vomiting). Since the client is vomiting, the nurse should first observe the color and appearance of the emesis for any obvious bleeding or other indications of risk to the client's homeostasis. Obtain a STAT blood pressure. The nurse will need to obtain a blood pressure, but that is not a priority at this time, as it might be elevated secondary to the vomiting.

The nurse is documenting the client's vomitus. Which documentation should be included in the client's medical record? (Select all that apply.)

Client vomited green with undigested food particles. It is important for the nurse to describe the appearance of the emesis, which includes the color. Vomit without odor. It is important for the nurse to describe any odor of the emesis, which could indicate the presence of blood, undigested foods, or fecal contaminant. Vomit is soft in consistency. This is not characteristics of emesis. Approximately 250ml of vomit was noted. It is important for the nurse to describe the volume or amount of emesis. Client vomited x 1 lasting approximately 2 minutes. The duration will describe if the episodes of vomiting were short, sporadic, ongoing, or intermittent.

While inspecting the client's abdomen, the nurse notes the following: Abdomen is rounded and symmetrical. No bulges or masses seen. Umbilicus is inverted and midline. No rashes noted. Silvery white striae noted on the lower abdomen. A four centimeter scar is noted on the right lower quadrant of the abdomen. No visible pulsations or perstalsis noted. No hair noted What statements from the client's focused interview correlate to the abnormal inspection findings? (Select all that apply.).

Daily bowel movements This information is not related to the development of striae or external scarring. Past surgical history of an appendectomy. Appendectomy scars will usually be present in the right lower quadrant. Nausea and vomiting. Nausea and vomiting does not cause striae or external scarring. Food intolerance to spicy foods. Striae are not related to food intolerance. . Change in body mass index (BMI). Striae are the result of a change in skin pigmentation that occurs following significant stretching of the elastic fibers of the skin on the abdomen. Causes can include obesity or pregnancy.

What additional focused interview questions will be important for the nurse to ask the client?

Do you have a history of any abdominal conditions or surgeries? Important to establish baseline of what has occurred in the client's past. Have you experienced any weight gain or weight loss? Weight gain or loss can be indicative of more complex GI problems or a side effect of certain medications. Are you have any difficulty with urination? This is an important question but not indicated given the client's symptoms. Are you experiencing any shortness of breath? This is an important question but not indicated given the client's symptoms. Do you have any difficulty swallowing your food? This is an important question but not indicated given the client's symptoms.

The nurse prepares the client for the physical assessment of the abdomen. What actions should the nurse take prior to initiating the assessment? (Select all that apply.)

Encourage the client to empty her bladder. Emptying the bladder will help promote relaxation of the abdominal wall. Place a pillow under the client's knees. Placing a pillow under the client's knees promotes relaxation of the abdominal muscles. Inquire where the client is experiencing pain. This guides the nurse with the examination during percussion and palpation. Quadrants with pain are examined last due to muscle guarding. Instruct the client to place her hands over her head. Placing the hands over the head can cause the abdominal muscles to tense. Discuss the sequence of steps performed during the abdominal assessment. Telling the client what to expect during a procedure helps promote relaxation.

In response to the client's statement that she is in a lot of pain, what action should the nurse take first?

Explain to the client that post-operative pain is normal. This is a non-therapeutic response to the client's current situation. Ask the client to describe her pain location and intensity. The nurse should begin by gathering further data about the pain, including location, intensity, and quality. Ask the client if she has passed gas since surgery. This question may be relevant, but other actions have priority. Jarvis, C., Eckhardt, A., & Thomas, P. (2020). Physical examination & health assessment. St. Louis, MO: Elsevier. p. 167. Assess the client's heart rate and blood pressure. This action may be warranted, but it is not the first action the nurse should implement when the client reports pain.

The nurse assesses the patient's vomitus. Which finding would the nurse be the most concerned about?

Green vomit with particles of food. Not the most concerning. Green may indicate the presence of bile. This is typically found in the small intestine but can be found in vomit if the patient has eaten recently. Can also indicate presence of medical problem so should be followed up on. Particles of food is a normal finding if the patient just ate. Thick dark brown vomit Thick dark brown vomit may indicate the presents of stool or blood. This is an abnormal finding that would need to be investigated and communicated. White foamy vomit White foamy vomit indicates the presence of stomach acid. Yellow clear vomit Not the most concerning finding. Yellow may indicate the presence of bile. This is typically found in the small intestine but can be found in vomit if the patient has eaten recently. Can also indicate presence of medical problem so should be followed up on.

Management of Care Fifteen minutes after receiving the antiemetic, the client stops vomiting, appears relaxed, and denies further nausea. She states that she is comfortable enough for the nurse to begin the admission assessment. The nurse questions the client about what brought her to the hospital. The client states she had right upper quadrant abdominal pain, nausea and vomiting right after she ate lunch. Pain remains at 5/10. The client states her last bowel movement was yesterday. For the nurse to learn about the client's bowel patterns, which questions are most important to ask the client? (Select all that apply.)

Have you had any recent onset of heartburn? While the onset of heartburn may be important, this is not specific to bowel patterns. Do you take any prescription or over-the-counter medications? Medications can cause adverse GI effects. Assess for presence of laxatives, stool softeners, or antidiarrheal medications. Have you had any changes in your bowel movements? Changes in bowel habits can be due to various etiologies, such as diet, stress, activity, and medications. What is the color and consistency of your bowel movements? Black or red stools can indicate the presence of bleeding in the GI system. Establishing a baseline of what a normal for the client is important for further assessment. How often do you have a bowel movement? This information is an important part of the client's history. It establishes a baseline for assessment purposes.

inspection of abdomen

Inspect the skin, and note any of these findings: • Overall asymmetry of the abdomen • Presence of discolorations or scarring • Abdominal distention • Bulging flanks • Taut, glistening skin The contour of the abdomen can be rounded, flat, concave, or distended. It is best determined when standing at the side of the bed or treatment table and looking down on the abdomen. View the abdomen at eye level from the side. Note whether the contour is symmetric or asymmetric. Asymmetry of the abdomen can indicate problems affecting the underlying body structures. Note the shape and position of the umbilicus for any deviations. - observe the patient's abdominal movements, including the normal rising and falling with inspiration and expiration, and note any distress during movement. Occasionally, pulsations may be visible, particularly in the area of the abdominal aorta. -If a bulging, pulsating mass is present during the assessment of the abdomen, do not touch the area because the patient may have an abdominal aortic aneurysm, a life-threatening problem. Notify the health care provider of this finding immediately! Peristaltic movements are rarely seen unless the patient is thin and has increased peristalsis. If these movements are observed, note the quadrant of origin and the direction of peristaltic flow. Report this finding to the health care provider because it may indicate an intestinal obstruction.

What further assessment technique would the nurse consider to confirm a problem with the gallbladder?

Murphy's sign Pain is elicited when gallbladder inflammation is present. Illiopsoas test Indicated with a suspected appendicitis. Obturator test An inflamed appedix elicits a painful response with this test. The Alvarado score This test is used to assess right lower quadrant pain.

When completing the pain assessment, how should the nurse assess for rebound tenderness?

Position the client on her right side. It is not necessary to position the client on her side. Lightly palpate over the painful area. When assessing for rebound tenderness, palpation should not be performed over the painful area. Ask the client to describe the pain. A description of the client's pain is not part of the assessment for rebound tenderness. Push down on the left side of the abdomen. After applying pressure at a site away from the area of pain, the nurse quickly lifts and removes the hand from the client's abdomen. Pain upon release of the pressure is referred to as rebound tenderness.

A dull sound is heard when the nurse percusses over the suprapubic area. What action should the nurse take in response to this finding?

Reposition the client to her right side. Repositioning the client will not change the sound heard upon percussion of the lower abdomen. Observe the area for bladder distention. A dull sound upon percussion may be heard over a distended bladder. Determine if the client feels bloated or gaseous. Gaseous distention may cause a hyperresonant sound. Assist the client to a sitting position immediately. This action is not warranted in response to this finding.

The nurse listens in all areas and hears gurgling sounds at each location between 8 to 20 sounds per minute. After auscultating the client's bowel sounds, the nurse also listens for abdominal vascular sounds, which are soft, low-pitched, and continuous. The nurse does not hear any venous sounds.

Stop the assessment and notify the healthcare provider (HCP) immediately of the assessment finding. This finding does not require notification of the HCP. Take the client's blood pressure and heart rate after the assessment. This finding does not require immediate assessment of the vital signs. Call another nurse to verify the finding. Abdominal vascular sounds are not normally heard, so getting another nurse to verify the finding is not necessary. Document this normal finding on the client's assessment record. Abdominal vascular sounds are not normally heard, so the only action necessary is to record this normal finding on the assessment record.

What action should the nurse take?

Use the client's own hand to assist with palpation. The nurse will place their hand over the client's hand and fingers. People are not ticklish to themselves. Switch to using the heel of the hand to palpate. The heel of the hand should not be used. Obtain an order for a muscle relaxant. The nurse is using the correct amount of pressure and does not need to decrease the amount of pressure applied. Stop any further palpation immediately. Discontinuing further palpation is not warranted.

When continuing to assess the abdominal area, the nurse hears a swishing sound. In what area would this sound be heard?

femoral artery. This area would produce a swishing sound that occurs during systole (vascular sounds). Epigastric area. The midline areas would not produce this sound. Umbilical area. The umbilical area would not produce this sound. Right quadrants. The right quadrants would not produce this sound.

To learn about the intensity of the client's pain, what pain scale is most appropriate to use to assess the client's pain?

FLACC behavioral pain scale This is most appropriate for infants and toddlers. Numeric pain scale A numeric pain scale is an effective tool for measuring pain intensity. A numeric pain scale is an effective tool for measuring pain intensity. Faces Pain scale Usually indicated for children but can be used for adults that are non-verbal. Patient is able to verbalize pain. Non-verbal cues While this assessment is important, it does not provide information about the intensity of the client's pain

The nurse is assessing for costo-vertebral angle (CVA) tenderness. Which statements best describe this percussion assessment? (Select all that apply.)

it is normal for a client to feel pain with this percussion assessment. Incorrect, pain is only present if kidney inflammation is present. This is an abnormal finding. Percussion is completed over the 12th rib in the back bilaterally. Correct, Percussion is completed over the 12th rib at the CVA angle in the back bilaterally. Place one hand over the flank area and hit the hand with the ulnar side of the fist. Correct, Place one hand palm side down and strike the hand with the ulnar side of your fist gently. Client will need to take a deep breath prior to completion of the percussion technique. Incorrect, The client does not have to hold their breath during this assessment technique. . Technique is used to assess for inflamation of the kidney. Correct, pain illicited during this technique may indicate inflamation of the kidney.

massive ascites

- may cause renal vasoconstriction, triggering the renin-angiotensin system. *This results in sodium and water retention, which increases hydrostatic pressure and the vascular volume and leads to more ascites. -distended abdomen with bulging flanks -orthopnea and dyspnea from increased abdominal distention can interfere with lung expansion. The patient may have difficulty maintaining an erect body posture, and problems with balance may affect walking. Inspect and palpate for the presence of inguinal or umbilical hernias, which are likely to develop because of increased intra-abdominal pressure. Minimal ascites is often more difficult to detect, especially in obese patient. Patient with abdominal ascites in late-stage cirrhosis. When performing an assessment of the abdomen, keep in mind that hepatomegaly (liver enlargement) occurs in many cases of early cirrhosis. Splenomegaly is common in nonalcoholic causes of cirrhosis. As the liver deteriorates, it may become hard and small. Measure the patient's abdominal girth to evaluate the progression of ascites. To measure abdominal girth, the patient lies flat while the nurse or other examiner pulls a tape measure around the largest diameter (usually over the umbilicus) of the abdomen. The girth is measured at the end of exhalation. Mark the abdominal skin and flanks to ensure the same tape measure placement on subsequent readings. Taking daily weights, however, is the most reliable indicator of fluid retention.

The nurse is completing an inspection of the abdomen. Which findings would cue the nurse of the need for action?

The presence of striae on the right and left lower quadrants. Do not require further work up. Striae occur when elastic fibers in the reticular layer of the skin are broken after rapid or prolonged stretching as in pregnancy or excessive weight gain. A protruberant shaped abdomen. A protruberant shaped abdomen indicates abdominal distention. A midline, inverted umbilicus. A midline, inverted umbilicus is an expected finding. A large amount of pigmented nevi scattered accross the abdomen. Pigmented nevi or moles are a common finding on the abdomen. Marked visible peristalsis. Visible peristalsis may be seen in very thin people. Especially in the presence of a protruberant abdomen may indicate a bowl obstruction and would require the nurse to follow up.

To ensure the most accurate assessment of the abdomen, what actions should the nurse take? (Place in order from first action through last action.)

1. Inspection. 2. Auscultation. 3. Percussion. 4. Palpation. The correct order of the assessment is inspection, auscultation, percussion, and palpation. Percussion and palpation of the abdomen may stimulate peristalsis, so inspection and then auscultation should be completed first to ensure an accurate assessment of peristalsis.

The client vomits 200 milliliters of yellow-green liquid. The client continues to feel nauseated. The nurse administers a PRN dose of a prescribed antiemetic. Shortly after the nurse administers the antiemetic, the client states she feels better. The nurse offers to provide oral care with a mint-flavored foam swab and cool water Which assessment takes priority while the nurse provides oral care?

Assess for presence of dentures. This information may be important, but another assessment takes priority at this time. Observe the condition of the mucus membranes. Because the client has a recent history of nausea, vomiting, and weight loss, the RN should assess the client for signs of fluid volume deficit, including observing the mucus membranes for excessive dryness. Evaluate the color of the gums Considering the client's recent history of nausea and vomiting, another assessment takes priority at this time. Check for the presence of cavities. Considering the client's recent history of nausea and vomiting, another assessment takes priority at this time.

Where should the nurse begin abdominal auscultation?

Right lower quadrant (RLQ) Place the stethoscope lightly on the abdominal wall, beginning in the RLQ in the area of the ileocecal valve, where bowel sounds are normally present. Proceed with listening to other quadrants in a systemic manner.

The nurse's goal in palpating the client's abdomen is to screen for any masses or tenderness. To achieve this goal, what action should the nurse take first?

Deeply palpate each abdominal organ. Deep palpation of the organs is not the first step when palpating the abdomen. Carefully palpate areas of tenderness. Palpation of any areas of tenderness should be saved for last to prevent resulting discomfort or muscle rigidity. Lightly palpate the abdominal surface. Light palpation allows the nurse to screen the abdomen for any obvious masses or tenderness before applying deeper palpation that may cause pain or rigidity. Gently palpate the edges of the liver. Deep palpation used to palpate the liver is not the first step when screening the abdomen.

After observing the presence of rebound tenderness, the nurse notes the onset of involuntary rigidity of the client's abdomen. Which action should the nurse implement?

-Notify the HCP of the findings. Rebound tenderness and involuntary rigidity (guarding) are abnormal findings associated with peritoneal irritation and are signs that should be reported to the HCP immediately for further diagnostic evaluation. Assist the client to a semi-Fowler's position. This action is not useful following the onset of involuntary rigidity (guarding). Administer a pain medication. More assessment is needed prior to the administration of a pain medication, which could mask other symptoms. Place a warm moist pack on the client's abdomen. This action is not useful following the onset of involuntary rigidity (guarding).

Pharmacological and Parenteral Therapies. After completing the pain assessment, the nurse prepares to administer a prescribed opioid analgesic: Morphine Sulfate 6 mg by intravenous push every 6 hours. Morphine is available in 10 mg/1 mL vials. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the tenth.)

0.6 (6/10)

The nurse notes eight high-pitched gurgling sounds occurring at irregular intervals in the right lower abdomen over 15 seconds.

-Move to the right upper quadrant (RUQ) to hear the sounds more distinctly. Client has complained of right upper quadrant pain so moving to that quadrant next is not advised. Continue to auscultate for bowel sounds in the right lower quadrant. The pattern of bowel sounds is typically irregular and the duration of bowel sounds may range from 1 second to several seconds. Expected amount of bowel sounds is between 8-30 over 1 minute. Need to assess if bowel sounds are hypoactive, hyperactive, or normal. Change to the bell of the stethoscope to listen. The diaphragm of the stethoscope should be used to listen to bowel sounds. Listen for 5 minutes before documenting the activity of the bowel sounds. If bowel sounds are not heard, the nurse should listen for 5 minutes to allow sufficient time before documenting the absence of bowel sounds. If bowel sounds are heard, it is not necessary to continue to listen for 5 minutes.

Thirty minutes later, the nurse returns to assess the client's response to the medication. Which findings provide the best data about the effectiveness of the medication? (Select all that apply.)

The client's vital signs are within normal limits. The client's vital signs (within normal limits) provide useful data about the client's response to pain. The client is holding a pillow over her abdomen. The client's actions may provide useful data about her response to pain, but they are not the most useful source of information about the effectiveness of an analgesic. The client's facial expression is calm and relaxed. The client's nonverbal behavior can provide valuable data about her response to pain, and it is a useful source of information about the effectiveness of an analgesic. The client states a lessening of her pain. The client's subjective report regarding her pain is important information for the nurse to assess when evaluating the effectiveness of analgesic administration. The spouse reports that the client looks like her pain has improved. This input is not the most useful data for the nurse as it is not the patient's own description of the effectiveness of the medication.