Case Study Abdominal Assessment

The nurse continues to gather additional data.Pharmacological and Parenteral TherapiesAfter completing the pain assessment, the nurse prepares to administer a prescribed opioid analgesic: Morphine Sulfate 10 mg by intravenous push every 6 hours. Morphine is available in 25 mg/1 mL vials. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the tenth.)

0.4 Desired dose divided by Dose on hand = Dose to give25 mg/1 mL: x/10 = 0.4 mL

Thirty minutes later, the nurse returns to assess Claudine's response to the medication. Which findings provide the best data about the effectiveness of the medication?

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'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.

To learn about the intensity of the client's pain, what action should the nurse take?

Encourage the client to use a numeric pain scale to rate her pain. A numeric pain scale is an effective tool for measuring pain intensity.

Claudine proudly tells the nurse that although she is still overweight, she has lost more than 50 pounds in the last year and a half. After inspecting the abdomen, the nurse prepares to assess the client's bowel sounds. To ensure the most accurate assessment of peristalsis, what action 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.

Health Promotion and Maintenance After the nurse reports the findings to the HCP, Claudine is scheduled for immediate surgery. Following surgery, Claudine returns to her room. During the nursing assessment on the first postoperative day, Claudine seems anxious and tells the nurse that she hurts a lot.In response to the client's statement that she hurts a lot, what action should the nurse take first?

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.

The nurse asks Claudine if there are any foods she cannot eat, and Claudine reports that she doesn't tolerate spicy foods. What questions should the nurse ask next?

Can you identify which spicy foods cause a problem? This information will be helpful in planning interventions for meal preparation. What happens when you eat spicy foods? Claudine's response is the most useful regarding the nature of her inability to eat spicy foods and any underlying problems. Do you remember when you developed this intolerance to spicy foods? This information is useful in assessing the client's inability to eat spicy foods.

During report, the nurse also describes the client's earlier emesis. The nurse should describe the emesis in terms of which characteristics?

Color. It is important for the nurse to describe the appearance of the emesis, which includes the color 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. Volume. It is important for the nurse to describe the volume or amount of emesis. Duration. The duration will describe if the episodes of vomiting were short, sporadic, ongoing, or intermittent.

Health Promotion and Maintenance The nurse first listens for bowel sounds in the right lower quadrant (RLQ) and hears high-pitched gurgling sounds that occur irregularly. What action should the nurse take next?

Continue to listen over the RLQ for 5 to 15 seconds. The pattern of bowel sounds is typically irregular and the duration of bowel sounds may range from 1 second to several seconds. Bowel sounds should be noted every 5 to 15 seconds.

The nurse listens in all areas and hears gurgling sounds at each location between 8 to 20 sounds per minute. How should the nurse document the assessment?

Normal bowel sounds. Normal bowel sounds occur irregularly, approximately 5 to 30 times per minute.

Fifteen minutes after receiving the antiemetic, Mrs. McElroy stops vomiting, appears relaxed, and denies further nausea. She states that she is comfortable enough for the nurse to begin the admission assessment and asks that the nurse call her Claudine. The nurse begins the client interview, focusing on the gastrointestinal system. For the nurse to learn about Claudine's bowel patterns, which questions are most important to ask Claudine?

Do you take any prescription or over-the-counter medications? Medications can cause adverse GI effects. Have you noticed any change in your stool pattern? Changes in bowel habits can be due to various etiologies, such as diet, stress, activity and medications. Do you have any difficulty with defecation? To fully assess the client's bowel patterns, it is essential to obtain information related to any difficulty with defecation, such as straining or pain. Do you have frequent vomiting episodes? This information is an important part of the client's history.

The assessment reveals that the client's abdomen is symmetrical with no masses, bulges, or pulsation of the abdominal aorta observed. The nurse notes dark brown pigmentation on the abdominal area. Which action is most important for the nurse to perform next?

Document the finding as normal. This is a normal finding in the African American client. The nurse should document the finding.

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. What action should the nurse take in response to this finding?

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.

Health Promotion and Maintenance After completing the client interview, the nurse is ready to begin the physical assessment of the abdomen. The nurse prepares Claudine for the physical assessment of the abdomen. Before assisting her to a supine position, what action should the nurse take?

Encourage the client to empty her bladder. Emptying the bladder will help promote relaxation of the abdominal wall. Discuss the sequence of steps performed during the abdominal assessment. Telling the client what to expect during a procedure helps promote relaxation.

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.

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?

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.

While percussing the abdomen, the nurse hears tympany over most of the abdomen but notes a duller sound when percussing at the right costal margin. Which is the most appropriate follow up action the nurse should implement?

Note this location as the border of the liver. Dullness upon percussion is generally heard over organs, such as the liver. The right costal margin is the location at which abdominal tympany should change to dullness over the liver border. This location is useful in determining liver span. Document the finding as normal. The right costal margin is the location at which abdominal tympany should change to dullness over the liver border.

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.

Mrs. McElroy continues to feel nauseated and Mr. McElroy remains with his wife while the nurse leaves the room to prepare a PRN dose of a prescribed antiemetic. Shortly after the nurse administers the antiemetic, Mrs. McElroy 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?

Observe for excessive dryness 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.

After completing the preparations, the nurse assists Claudine to a supine position on the bed. To assess the symmetry of the abdomen, what action should the nurse take?

Observe the abdomen from two different angles. To evaluate symmetry, the nurse should stand behind the client's head and squat at the side to view the abdomen at eye level.

Health Promotion and MaintenanceAfter completing auscultation of the client's abdomen, the nurse prepares to percuss Claudine's abdomen.A dull sound is heard when the nurse percusses over the suprapubic area. What action should the nurse take in response to this finding?

Observe the area for bladder distention. A dull sound upon percussion may be heard over a distended bladder.

Management of CareMrs. McElroy is admitted to her room accompanied by her husband. Before the nurse can begin the admission assessment, Mrs. McElroy states that she needs to throw up. The nurse helps Mrs. McElroy sit up and provides an emesis basin.Mrs. McElroy 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?

Observe the color of the emesis. 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.

When beginning palpation of Claudine's abdomen, the nurse uses a circular finger motion to depress the client's skin about a half centimeter. While palpating, the nurse observes that the Claudine's superficial abdominal muscles are tensing bilaterally. What action should the nurse take?

Observe the muscles while the client exhales. Bilateral tensing is often an indication of voluntary guarding by the client. To help distinguish between voluntary and involuntary guarding, the nurse should observe the muscles during exhalation because the client usually does not demonstrate voluntary guarding during exhalation.

While inspecting Claudine's abdomen, the nurse observes silvery white striae on the lower abdomen. In response to this finding, what information should the nurse obtain?

Past medical history of ascites. 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 ascites (fluid collection in the peritoneal cavity). 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.

Health Promotion and Maintenance Three hours later, Claudine's husband calls the nurse, stating that she is reporting increased abdominal pain. The nurse asks Claudine where she is experiencing pain and she points to her right lower abdomen.When completing the pain assessment, how should the nurse assess 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.

After palpating Claudine's abdomen, the nurse observes that Claudine is very fatigued. She states that the nausea medication has made her very sleepy. The nurse concludes the assessment to allow Claudine to rest. Which information is most important to report to the nurse assuming responsibility for Claudine's care?

What time the client received an antiemetic. This information is essential to report to the nurse assuming responsibility for the client to ensure client safety after receiving a sedating medication.