Abdominal Assessment vocabulary

The nurse suspects a patient has appendicitis what 2 procedures do you use?

1. Blumberg's sign 2. perform iliopsoas muscle test

What is the correct sequence for auscultation of the abdomen?

1. RLQ 2. RUQ 3. LUQ 4. LLQ if there is pain present, then maintain a systemic approach ex: pain in RUQ 1. RLQ always do first because bowel sounds are normally present here 2. LLQ (compare 2 lower quadrants) 3. LUQ 4. RUQ (done last due to the presence of pain)

What does a DULL sound over the suprapubic area upon percussion indicate?

Bladder distention

Which method would the nurse use to assess a client suspected of having a distended bladder? A. inspect and palpate the epigastric region B. auscultate and percuss the inguinal areas C. percuss and palpate the hypogastric region D. bilaterally percuss and palpate the lumbar regions

C. percuss and palpate the hypogastric region Hypogastric = pubic region percussion of a distended bladder would produce a dull sound and feel firm upon palpation

When preparing to assess the four abdominal quadrants of a client who reports stomach pain, when would the nurse assess the symptomatic quadrant? A. first B. second C. third D. last

D. last the nurse would systematically assess the abdomen concluding with the symptomatic area which is the area in which the client reports pain pain may be elicited in the symptomatic area if assessed first, second, or third, causing the muscles in other abdominal areas to tighten. This would interfere w/ the assessment

What color vomit is most concerning?

Dark brown it indicates the presence of stool or blood

What sound is generally heard over organs ?

Dullness upon percussion

What are the 4 steps of an abdominal assessment?

Inspection Auscultation Percussion Palpation

What action should the nurse take first when screening for any masses or tenderness?

Lightly palpate the abdominal surface allows the nurse to screen the abdomen for obvious masses or tenderness BEFORE applying deeper palpation

Are abdominal vascular/venous sounds normal?

No

Are rebound tenderness and involuntary rigidity normal findings?

No they should be notified to the HCP

Murphy's sign is __________ with palpation of _______ ______________

Pain with palpation of gall bladder (seen with cholecystitis)

Why does a duller sound occur at the right costal margin? Is this normal?

The Right Costal Margin is where the liver border is This is a normal sound

Liver failure is characterized by:

fluid in abdomen jaundice

Appendicitis; characterized by pain where?

inflammation of the appendix Characterized by RLQ pain

Cholecystitis; characterized by pain where?

inflammation of the gallbladder Characterized by RUQ pain, nausea, and vomiting after eating

What is CVA technique used to assess for?

inflammation of the kidney

peritonitis

inflammation of the peritoneum

gastroenteritis

inflammation of the stomach and intestines

Hypogastric

middle lower region below the umbilical region

What are symptoms of gastroenteritis?

nausea, vomiting, diarrhea

If a client has a history of nausea and vomiting, what is the priority assessment during oral care?

observe mucus membranes mucus membranes can indicate a FVD if there is excessive dryness

Ureteral colic

pain from a stone or blood clot in the ureter Characterized by flank pain that wraps around to the groin

What is rebound tenderness?

pain upon releasing the palpating hand pushing on the abdomen

Costo-vertebral angle Tenderness (CVA) is assessed by

percussing over the 12th rib placing one hand over the flank area and hitting the hand with pinky side of fist

hypoactive bowel sounds can be due to

peritonitis (inflamed lining of stomach)

How do you assess for rebound tenderness?

push down on the opposite side of the site of pain

What sound does the umbilical region make?

tympanic percussion

What sound is heard over most of the abdomen?

tympanic sounds