Ch. 23 Abdomen

*Left Lower Quadrant: (LLQ)

-Left kidney (lower pole) -Left ovary and tube -Left ureter -Left spermatic cord -Descending and sigmoid colon

*Left Upper Quadrant: (LUQ)

-Left adrenal gland -Left kidney (upper pole) -Left ureter -Pancreas (body and tail) -Spleen -*Part of Bowel -Splenic flexure of colon -Stomach -Transverse descending colon

Light Palpation:

-Light palpation used to identify areas of tenderness & muscular resistance -Use fingertips; begin palpation in a nontender quadrant; *press to a depth of 1cm. in a dipping motion; then lift fingers & move to next area -Minimize voluntary guarding (Box 23-2) -*AVOID TENDER AREAS UNTIL LAST -Light palpation performed BEFORE deep palpation -Overcome ticklishness & minimize voluntary guarding; have client perform self-palpation -Apply light pressure over sternum while palpating to relax abdominal muscles Normally the abdomen is nontender & soft w/no guarding -Involuntary reflex guarding often reflects peritoneal irritation; abdomen is rigid & rectus muscle fails to relax -Right-sided guarding w/cholecystitis

Obj. Data: Inspection Aortic pulsations

-May see slight pulsation from aorta, visible in epigastrium ABN.: -*VIGOUROUS, WIDE EXAGGERATED PULSATION W/ABDOMINAL AORTIC ANEURYSM* -Best screening for aneurysm is ultrasound *VERY IMPORTANT: -Recommended 1-time screening men 65-75 w/past hx of smoking(smoked at least 100 cigarettes in lifetime), for abd. AORTIC ANEURYSM *DO NOT PALPATE AN ANEURYSM*

Abdominal Aorta & Aneurysm

A sac formed by dilation in artery wall: -Atherosclerosis weakens the vessel walls; effect of BP creates the balloon enlargement -Most located below renal arteries, extending to umbilicus; feels like a pulsating mass to left of midline (don't palpate) -Audible bruit; decreased femoral pulses -Lower abdominal & lower back pain

Obj. Data: Auscultation

BEFORE percussing & palpating -*Done to avoid increasing peristalsis, & false interpretation of bowel sounds -Use diaphragm, warmed -Begin w/RLQ - ileocecal valve (Bowel S. usually present here) then proceed clockwise, all 4 quads *APPLY LIGHT PRESSURE OR REST ON A TENDER ABDOMEN*

Palpate the Urinary Bladder:

Palpate for a distended bladder when the client's hx. or other findings warrant Begin at the symphysis pubis & move upward & outward -An empty bladder in not palpable NOR tender *ABNORMAL -A distended bladder is palpated as smooth, round, & firm mass extending as far up as the umbilicus -Would be dull to percussion

BOX 23-2 *CONSIDERATIONS FOR PALPATING THE ABDOMEN

• Avoid touching tender or painful areas *UNTIL LAST, and reassure the client of your intentions. • Perform light palpation *BEFORE deep palpation to detect tenderness and superficial masses. • Keep in mind that the normal abdomen *MAY be tender, especially in the areas over the xiphoid process, liver, aorta, lower pole of the kidney, gas-filled cecum, sigmoid colon, and ovaries. • Overcome ticklishness and minimize voluntary guarding by asking the client to perform self-palpation. Place your hands over the client's. After a while, let your fingers glide slowly onto the abdomen while still resting mostly on the client's fingers. The same can be done by using a warm stethoscope as a palpating instrument—again letting your fingers drift over the edge of the diaphragm—and palpate without promoting a ticklish response. • Work with the client to promote relaxation and minimize voluntary guarding. Use the following techniques: ○ Place a pillow under the client's knees. ○ Ask the client to take slow, deep breaths through the mouth. ○ Apply light pressure over the client's sternum with your left hand while palpating with the right. This encourages the client to relax the abdominal muscles during breathing against sternal resistance.

*BOX 23-1 MECHANISMS AND SOURCES OF ABDOMINAL PAIN TYPES OF PAIN Abdominal pain may be formally described as visceral, parietal, or *referred.

• Visceral pain occurs when hollow abdominal organs—such as the intestines—become distended or contract forcefully, or when the capsules of solid organs such as the liver and spleen are stretched. Poorly defined or localized and intermittently timed, this type of pain is often characterized as dull, aching, burning, cramping, or colicky. • Parietal pain occurs when the parietal peritoneum becomes inflamed, as in appendicitis or peritonitis. This type of pain tends to localize more to the source and is characterized as a more severe and steady pain. • ***Referred pain: occurs at distant sites that are innervated at approximately the same levels as the disrupted abdominal organ. This type of pain travels, or refers, from the primary site and becomes highly localized at the distant site. The accompanying illustrations show common clinical patterns and referents of pain.

Palpation: Umbilicus & Aorta

Palpate umbilicus & surrounding areas for bulges or masses -Normally free of swelling, bulges or masses -A soft center can be a potential for herniation -A hard nodule may indicate metastatic nodes from an occult GI cancer The Aorta is not routinely palpated; in clients older than 50 w/suspected aneurysm, may palpate width (wide, bounding pulse may be aneurysm) -DO NOT PALPATE A PULSATING MIDLINE MASS; may be a dissecting sneurysm, may rupture

Newborns/Infants:

-Umbilical cord has 2 arteries, 1 vein -Peristaltic waves may be visible -Liver may be palpated in healthy term neonate -ABDOMINAL WALL is LESS MUSCULAR, easier to PALPATE ORGANS

*Midline:

-Bladder -Uterus -Prostate gland

Subj. Data: Child/Adolescents

-Excessive vomiting -Abdominal pain -Digestive problems (i.e. irritable bowel, constipation) -Abdominal trauma -Abdominal hernias is input matching output urine dark? dehydration

Patterns and referents of abdominal pain. CHARACTER OF ABDOMINAL PAIN AND IMPLICATIONS

*Dull, Aching Appendicitis Acute hepatitis Biliary colic Cholecystitis Cystitis Dyspepsia Glomerulonephritis Incarcerated or strangulated hernia Irritable bowel syndrome Hepatocellular cancer Pancreatitis Pancreatic cancer Perforated gastric or duodenal ulcer Peritonitis Peptic ulcer disease Prostatitis *Burning, Gnawing Dyspepsia Peptic ulcer disease Cramping ("crampy") Acute mechanical obstruction Appendicitis Colitis Diverticulitis Gastroesophageal reflux disease (GERD) *Pressure Benign prostatic hypertrophy Prostate cancer Prostatitis Urinary retention *Colicky Colon cancer *Sharp, Knifelike Splenic abscess Splenic rupture Renal colic Renal tumor Ureteral colic Vascular liver tumor *Variable Stomach cancer

*ABNORMAL FINDINGS 23-3 Enlarged Abdominal Organs and Other Abnormalities -Enlarged liver, enlarged nodular liver, enlarged spleen, enlarged bladder, aortic aneurysm

*ENLARGED LIVER: An enlarged liver (hepatomegaly) is defined as a span greater than 12 cm at the midclavicular line (MCL) and greater than 8 cm at the midsternal line (MSL). An enlarged nontender liver suggests cirrhosis. An enlarged tender liver suggests congestive heart failure, acute hepatitis, or abscess. *Enlarged liver. *ENLARGED NODULAR LIVER: An enlarged firm, hard, nodular liver suggests cancer. Other causes may be late cirrhosis or syphilis. *Enlarged nodular liver. *LIVER HIGHER THAN NORMAL: A liver that is in a higher position than normal span may be caused by an abdominal mass, ascites, or a paralyzed diaphragm. Liver higher than normal. LIVER LOWER THAN NORMAL A liver in a lower position than normal with a normal span may be caused by emphysema because the diaphragm is low. Liver lower than normal. *ENLARGED SPLEEN An enlarged spleen (splenomegaly) is defined by an area of dullness exceeding 7 cm. When enlarged, the spleen progresses downward and toward the midline. Enlarged spleen. *AORTIC ANEURYSM A prominent, laterally pulsating mass above the umbilicus strongly suggests an aortic aneurysm. It is accompanied by a bruit and a wide, bounding pulse. Aortic aneurysm. ENLARGED KIDNEY An enlarged kidney may be due to a cyst, tumor, or hydronephrosis. It may be differentiated from an enlarged spleen by its smooth rather than sharp edge, the absence of a notch, and tympany on percussion. Enlarged kidney. *ENLARGED GALLBLADDER An extremely tender, enlarged gallbladder suggests acute cholecystitis. A positive finding is Murphy sign (sharp pain that causes the client to hold the breath). Enlarged gallbladder.

Subjective Data: (Indigestion, N/V, Meds., elimination, Hx., lifestyle/health)

*Indigestion (pyrosis) (heartburn): -GERD, peptic ulcer, stomach cancer Naseua/vomiting: -Liver, pancreas, renal, dietary intolerances, morning sickness *Appetite: -change, loss, change in weight, over what period of time, intentional? -ANOREXIA: (loss of appetite that occurs w/GI dz., side effects of meds., pregnancy, psychological disorders) Women - LMP MEDICATIONS (Zofran) *Bowel elimination: -Description -Change in pattern, color of stool, constipation, diarrhea Yellowing of skin -Past abdominal Hx. -UTI, GI disorder, pancreatiitis, gallbladder, hepatitis Lifestyle/Health -ETOH, stress

*23-1 EVIDENCE-BASED HEALTH PROMOTION AND DISEASE PREVENTION: Peptic Ulcer Disease -Risk Assessment

*Risk factors that can be controlled (are *modifiable): • Use of NSAIDs or bisphosphonates (Actonel, Fosamax, etc.) • Smoking or chewing tobacco *Risk factors that cannot be controlled (are *nonmodifiable): • Presence of H. pylori in gastrointestinal tract • Stress (findings differ on whether or not stress is a factor) • Hypersecretory condition, in which the stomach produces too much acid • A personal or family history of ulcers (suspected genetic link) • Radiation treatments Zollinger-Ellison syndrome (rare condition of a tumor in the pancreas that releases a high level of an acid-producing hormone)

Obj. Data: Preparation

-Empty bladder 1st Help promote abdominal muscle relaxation: -overcome ticklishness -position supine, head on pillow, knees slightly flexed; arms @side OR hands resting on center of chest -*DO NOT put arms above head, tenses abd. muscles -provide a warm environment -warm hands & stethoscope -provide privacy REMEMBER EXAMINE PAINFUL AREAS LAST STAND ON PERSON'S RIGHT SIDE & LOOK DOWN -Need good lighting + tangential lighting as needed

*ABNORMAL FINDINGS 23-2 Abdominal Bulges -Umbilical hernia & incisional hernia

*UMBILICAL HERNIA: An umbilical hernia results from the bowel protruding through a weakness in the umbilical ring. This condition occurs more frequently in infants, but also occurs in adults. EPIGASTRIC HERNIA: An epigastric hernia occurs when the bowel protrudes through a weakness in the linea alba. The small bulge appears midline between the xiphoid process and the umbilicus. It may be discovered only on palpation. DIASTASIS RECTI: Diastasis recti occurs when the bowel protrudes through a separation between the two rectus abdominis muscles. It appears as a midline ridge. The bulge may appear only when the client raises the head or coughs. The condition is of little significance. *INCISIONAL HERNIA: An incisional hernia occurs when the bowel protrudes through a defect or weakness resulting from a surgical incision. It appears as a bulge near a surgical scar on the abdomen.

Obj. Data Inspection: Assess abdominal symmetry

-*Asymmetric ABN.- seen w/*ORGAN ENLARGEMENT, MASSES or BOWEL OBSTRUCTION If indicated, assess for hernias or mass -Ask client to raise head; normally no bulge -*A HERNIA IS SEEN AS BULGING into ABDOMINAL WALL -*(Abn. Findings p. 504 umilical & incisional hernias) -Inspect abdominal movement; respiratory movement may been seen in males

*Right Lower Quadrant: (RLQ)

-Appendix -Ascending colon -Cecum -Right kidney (lower pole) -Right ovary and tube -Right ureter -Right spermatic cord

ASSESSMENT GUIDE 23-1 Locating Abdominal Structures by Quadrants Abdominal assessment findings are commonly allocated to the quadrant in which they are discovered, or their location may be described according to the nine abdominal regions that some practitioners may still use as reference marks. Quadrants and contents are listed here. *Right Upper Quadrant: (RUQ)

-Ascending and transverse colon -Duodenum -*Gallbladder -Hepatic flexure of colon -*Liver -Pancreas (head) -*Part of bowel -Pylorus (the small bowel—or -ileum—traverses all quadrants) -Right adrenal gland -Right kidney (upper pole) -Right ureter

Subj. Data: Childbearing Woman

-Bloody stools -Change in bowel habits -Nausea or vomiting -Increased thirst -Women of childbearing age->ask for LMP (last menstrual period) -when assessing & ruling out cause of abdominal pain

Subjective Data: Newborns/Infants

-Breast/bottle fed -What foods eaten -Excessive vomiting -Appearance of abdominal pain (drawing up of knees); crying w/eating or w/bowel movement

Subj. Data: Aging Adult

-CHANGE IN APPETITE -Difficulty swallowing or feeling of choking -N/V -Problems w/bowel movements or change in bowel habits recently -Blood in stools -Medications taken

Deep Palpation: (not routinely performed)

-Deeply palpate all quadrants to delineate abdominal organs & detect subtle masses -Figure 23-20 Normally paplable structures -Use palmar surface of fingers; press 5-6cm. -Normal mild tenderness is possible; no masses are present -Severe tenderness or pain may be related to trauma, peritonitis, infection, tumors, or enlarged or diseased organs -Masses may be due to tumor, cyst, enlarged organ, aneurysm or adhesions

Obj. Data: Inspection for Peristaltic Waves

-Normally only in thin ppl -Seen w/*INTESTINAL OBSTRUCTION* -Demeanor should be relaxed -*w/PAIN may see RESTLESSNESS V. EXTREME STILLNESS V. KNEES & GRIMACING w/PAIN* Restleness may occur: -w/pain of gastroenteritis or bowel obstruction Absoulte stillness: -is commonly seen w/pain of Peritonitis or Appendicitis

Child/Adolescent:

-Prominent abdomen, POT-BELLY in toddlers -Right Kidney could be palpable in young children -Liver & spleen easily palpable in small children

Childbearing Woman

-Rectus abdominis muscles stretch; may result in diastasis recti (separation) -*Expanding uterus puts pressure on bladder, kidney & ureters (*BLADDER not in same position) -Enlarging uterus puts pressure on & displaces small intestine -Decreased gastric motility -Constipation -Pressure on intestines -Constipation -Heartburn -Gallstones may develop -Carbohydrate metabolsim is altered; develops hypoglycemia in 1st trimester; in 3rd trimester may see hyperglycemia

Obj. Data: Inspection Umblilucs, location, contour

-Skin tones similar to surrounding skin or pinkish -Midline- round, inverte, small eversion/protruding (normally) ABN.: -*DEVIATED W/MASS, ENLARGED ORGANS, FLUID or SCAR TISSUE -*EVERTED W/ABDOMINAL DISTENTION or HERNIA -CULLEN'S SIGN (BLUISH-PURPLE) from INTR-ABDOMINAL BLEEDING Inspect piercings for intactness; should be no redness or discharge

Childbearing Woman:

-Stria & linea nigra are normal findings on abdomen -Size of abdomen may indicate gestational age

Test for *Appendicitis: (not routinely performed by nurses) NOT tested on technique KNOW name of test & that pain on release confirms REBOUND TENDERNESS

-a RELIABLE sign of peritoneal inflammation accompanying appendicitis Assess when you elicit tenderness to palpation & pt. reports abdominal pain Assess for rebound tenderness; palpate deeply at 90 degrees into abdomen away from painful area -Sharp, stabbing pain w/release of pressure (Blumberg's sign) suggests peritoneal irritation from appendicitis Test for referred rebound tenderness--deep palpation in LLQ. Pain in RLG is + Rovsing's sign (appedicitis) Avoid continued palpation RT danger of rupturing appendix

Structure & Function: Abdomen

-large oval cavity extending from the diaphragm to the brim of the pelvis Abdominal wall muscels: -protect internal organs

*ASCITES

-occurs w/ cirrhosis, hepatitis, portal HTN or heart failure -often will see taut, glistening skin & increase in abdominal girth, sometimes dialted abdominal veins

Sources of Abdominal Pain: 1)Visceral Pain 2)Parietal Pain 3)Referred Pain

1)-Organs distended or stretched -Poorly defined or localized & intermittently timed -Dull, aching, burning, cramping, colicky 2)-Parietal peritoneum becomes inflamed -Localized to source, severe & steady 3)-Occurs at distant sites; travels or refers; become localized at distant site Know Box 23-1 Patterns of reffered pain

ASSESSMENT GUIDE 23-2 *Measuring Abdominal Girth In clients with abdominal distention, abdominal girth (circumference) should be assessed periodically (daily in hospital, during a doctor's office visit, with home nursing visits) to evaluate the progress or treatment of distention. Waist circumference measurement is also recommended in screening for cardiovascular risk factors.* To facilitate accurate assessment and interpretation, the following guidelines are recommended:

1. Measure abdominal girth at the same time of day, ideally in the morning just after voiding, or at a designated time for bedridden clients or those with indwelling catheters. 2. The ideal position for the client is standing; otherwise, the client should be in the supine position. The client's head may be slightly elevated (for orthopneic clients). The client should be in the same position for all measurements. 3. Use a disposable or easily cleaned tape measure. If a tape measure is not available, use a strip of cloth or gauze, then measure the gauze with a cloth tape measure or yardstick. 4. Place the tape measure behind the client and measure at the umbilicus. Use the umbilicus as a starting point when measuring abdominal girth, especially when distention is apparent. 5. Record the distance in designated units (inches or centimeters). Take all future measurements from the same location. Marking the abdomen with a ballpoint pen can help you identify the measuring site. As a courtesy, the nurse needs to explain the purpose of the marking pen and ask the client not to wash the mark off until it is no longer needed.

Test for Appendicitis:

A NORMAL, NEGATIVE response is no pain on release of pressure. ABNORMAL finding: -pain on release Assess for PSOAS SIGN: -Normally no pain -Pain in RLQ suggest inflamed appendix OBTURATOR SIGN: (ABN.) -No abdominal pain -Pain in RLQ suggests irritation of obruator muscle due to appendicitis or perforated appendix

Structure & Function: Abdominal Quadrants, See Assessment Guide 23-1 p. 474

4 Quadrants: RUQ, LUQ, RLQ, & LLQ -Imaginary vertical from Xiphoid through umbilicus -Also divided in 9 regions

Subjective Data: (pain, factors)COLDSPA:

Abdominal pain: -*Character:- may suggest origin-(dull, aching, knife-like, burning, gnawing, pressure, colicky, stabbing, throbbing,variable, etc.) -*Onset:-may suggest origin- Onset of pain is a diagnostic clue, whether sudden or gradual (Pain w/gastric ulcer is worse w/empty stomach) -*Location: Area, radiation (from abdominal organs or referred from other areas) -*Duration -Severity 0-10 -Pattern: Timing & relationsip of events may be a clue to origin of pain (What brings on, makes better/worse-position?, food?) -Precipitating factors: Alcohol, supine position, stress -Alleviating Factors: Antacids, H2 blockers -Associated Factors: Tarry stools, abdominal cramping, nausea, vomiting, diarrhea, weight loss, loss of energy

Acute Abdomen:

Acute/severe abdominal pain is almost always a symptom of intra-abdominal disease -May be the sole indicator of need for surgery; requires quick action -> perforation may occur RT interruption of abd. blood supply -RED FLAGS are signs of shock (tachycardia, hypotension, diaphoresis, confusion), signs of PERITONITIS, & abdominal distention along w/pain

Older Adults

Aging Adult: -FAT ACCUMULATES in the SUPRAPUBIC area in females RT decreased ESTROGEN -Males show fat deposits in abdominal area -Risk for complications w/diarrhea (fluid vol., dehydration, electrolyte) -Decreased salivation (causes dry mouth) -Gastric acid secretion decreases -*Gastfic motility changes (only so much space-> causes problems) *ABSORPTION in COLON* SMALL INTESTINE*(altered function, may not get what they need) -Constipation more common -Prone to UTIs RT decline in protective bacterial in urinary tract

Obj. Data: Inspection: lesions/rashes

Assess -Flat, brown moles normal; no rashes -*CHANGES IN MOLE; BLEEDING MOLES or PETECHIAE-> (bruising) =ABN.

Older Adults:

Assess GI motility; auscultate bowel sounds -Decrease in gastric emptying may cause early satiety; -Decreased GI motility RT general loss of muscle tone Determine if urinary retention is present Inspect abdomen; no obvious masses or enlarged organs Palpate for bladder distension ABNORMAL: -Abdominal distention, diarrhea, fluid overload, fluid & electrolyte imbalance

Test for Cholecystitis

Assess the RUQ for tenderness Press fingertips under liver border at the right costal margin & ask client to inhale deeply -No increase in pain is present -Accentuated shap pain that causes client to hold his breath (inspiratory arrest) is a positive Murphy's sign, associated w/cholecystitis

Obj. Data: Auscultate Vascular Sounds

Auscultate for BRUITS, especially in HTN clients or if you suspect Arterial Insufficiency to legs -Listen w/BELL for BRUITS over abdominal: -Aorta -Renal -Iliac & -Femoral arteries Normally no bruits Turbulent blood flow or obstruction w/aneurysm, stenosis, or obstruction of an artery -Confirm w/angiogram or ultrasound

*ABNORMAL FINDINGS 23-1 Abdominal Distention With the exception of pregnancy, abdominal distention is usually considered an abnormal finding. Percussion may help determine the cause. PREGNANCY (NORMAL FINDING) Pregnancy is included here so that the examiner may differentiate it from abnormal findings. It causes a generalized protuberant abdomen, protuberant umbilicus, a fetal heart beat that can be heard on auscultation, percussible tympany over the intestines, and dullness over the uterus.

FAT: Obesity accounts for most uniformly protuberant abdomens. The abdominal wall is thick, and tympany is the percussion tone elicited. The umbilicus usually appears sunken. FECES: Hard stools in the colon appear as a localized distention. Percussion over the area discloses dullness. FIBROIDS AND OTHER MASSES: A large ovarian cyst or fibroid tumor appears as generalized distention in the lower abdomen. The mass displaces bowel, thus the percussion tone over the distended area is dullness, with tympany at the periphery. The umbilicus may be everted. FLATUS: The abdomen distended with gas may appear as a generalized protuberance (as shown), or it may appear more localized. Tympany is the percussion tone over the area. ASCITIC FLUID: Fluid in the abdomen causes generalized protuberance, bulging flanks, and an everted umbilicus. Percussion reveals dullness over fluid (bottom of abdomen and flanks) and tympany over intestines (top of abdomen).

Cultural Considerations

Gallblader disease & GB cancer vary by ethnic group: -Native Americans & Mexican Americans have higher rates Stomach cancer associated w/H. pylori: -Lowest prevalence in the U.S. Cancer in general: -Low rate of cancer for Asian Americans but death rate from cancer is higher

Children & Adolescents:

NORMAL FINDINGS: -Child <4 abdomen looks protuberant; may have potbelly -Umbilicus is pink, no discharge, odor, redness, or herniation -Normal bowel sounds as in adults -Soft, no palpable masses ABNORMAL FINDINGS: -Same findings as newborn/infants -Rigid abdomen is an emergent problem -Enlarged liver, spleen, kidneys or bladder

Peritonitis:

Inflammation of peritonium caused by a bacterial or fungal infection Primary (rare) Secondary: -Infection enters peritoneum from GI or biliary tract -May be RT a tear in GI or biliary tract, i.e. pancreatitis, ruptured appendix, stomach ulcer, diverticulitis Often caused by liver disease; build-up of fluid creates an environment for bacterial growth SYMPTOMS: -Swelling & abdominal tenderness, pain ranging from dull ache to severe, sharp pain -Fever, chills, N/V, thirst, low urine output

Obj. Data: Examination: Sequence is Different Why?

Inspection (looking for pulsations, assesing, looking at distension) Auscultation PErcussion PAlpation (light palpation, displacing 1cm, no digging) To make sure a

Newborns & Infants:

NORMAL: -Abdomen is prominent in supine position -Umbilicus is pink, w/out discharge, odor, redness or herniation -Remnant of cord appears dried 24-48 hrs after birth -Normal bowel sounds -Abdomen soft to palpation w/out masses/tenderness -Liver is usually palbable 1-2cm. below right costal margin -Spleen, kidneys, & bladder may be palpable ABNORMAL: -Scaphoid abdomen w/malnutrition or dehydration; distended abdomen w/pyloric stenosis -Inflamed umbilicus w/infection -Diastasis recti w/immature musculature -Bulge at the umbilicus suggests hernia; may disapperar by age 1 -Abnormal vessels or color of cord -Marked peristaltic waves w/pyloric stenosis

Obj. Data: Auscultation

Normally: -you hear a series of soft clicks & gurgles, high-pitched (5-30X/min. don't count) -Hyperactive sounds, hyper-peristalsis (borborgmus); loud sounds (stomach growling) -Hyperactive CAN BE *abnormal, (high-pitched, tinkling sounds)- indicating rapid motility in early bowel obstruction, GE, brisk diarrhea, laxative use, & sbusiding paralytic ileus -Hypoactive/absent sounds: w/diminished motility, paralytic ileus, peritonitis or late bowel obstruction; following abdominal surgery or inflammation of peritoneum. -*Must listen for 5 min. before reporting no bowel sounds, 1 min. in each quadrant Note character & frequency of bowel sounds: -Bowel sounds return gradually post-op; small intestines in 1st few hrs; colon 3-5 days

Blunt Percussion for CVA (costavertebral angles) Tenderness *Focus on the Purpose

Nurses don't typically perform-advanced Done on the kidneys to assess for tenderness -Percuss at CVA over 12th rib -client sits w/back to you -client should perceive a dull thud -*Tenderness or sharp pain suggests KIDNEY INFECTION (PYELONEPHRITIS), RENAL CALCULI, OR HYDRONEPHROSIS

Obj. Data: Percussion *Do know this technique & how to perform

Nurses may or may not typically perform -Use indirect percussion to assess for tones & to assess density of abdominal contents, locate organs, screen for fluid or masses -Use same sequence as for auscultation, clockwise -*TYMPANY* should be heard in all 4 quads (air in intestines rises to surface when supine) -*DULLNESS (over SOLID THINGS) (EXPECTED SOUND OVER ORGAN, I.E. LIVER OR SPLEEN, FULL COLON) -*DULLNESS - *abnormal over distended bladder (suprapubic area)- would occur w/a severely distended urinary bladder -Dullness also over enlarged organ, masses or ascites (ALL ABNORMAL) *A dull sound over NO exam ?s on percussion of liver or spleen DO KNOW: -the normal Liver MAY or MAY NOT be palpable. If felt, should feel firm, smooth and even. Often the Liver is NOT palpale. ABNORMAL: DO KNOW: -hard, firm, or nodular liver, or one that is palpated MORE than 1-3cm. below right costal margin (enlargement) SPLEEN: Do KNOW: -that a palpable spleen suggests enlargement up to 3X its normal size; resulting from infections, trauma, mononucleosis, chronic blood disorders & cancers

Obj. Data: Inspect Skin:

Observe Coloration: -May be paler RT not exposed to sun -*PURPLE, YELLOW, PALE & TAUT, REDNESS, BRUISES Note vascularity: -Scattered fine veins may be visible -Abn.: *DILATED VEINS SEEN W/CIRRHOSSIS, *ASCITES, PORTAL HTN Observe any striae: -New striae vs. Older New= pink or bluish in color; older= striae silver, white, linear -Abn.: striae seen w/*Ascites -*DARK BLUISH PINK W/CUSHING'S SYNDROME -*MAY BE R/T ASCITES Inspect for Scars: -should be pale, smooth, min. raised & healed -Document size/location & healing; *ABN:NONHEALING wounds, redness, inflammation, deep & irregular, KELOIDS Document EX: -lower abdomen, striae LLQ -1 in. insitions, gall bladder surgery

Internal anatomy:

Parietal peritonium; thin, shiny serous membrane; provides protective covering for organs Abdominal Viscera: (Solid & hollow) Solid viscera: -Organs that maintain their shape consistently -*LIVER (extends just below R costal margin. MAY be palpable, should be soft consistency) PANCREAS, -*SPLEEN (soft mass/lymphatic tissue, NOT normally palpable) -*KIDNEYS (R K. rests 1-2cm. lower than L, b/c of placement of liver & MAY be palpable; the 12th rib forms the COSTOVERTEBRAL ANGLE w/the vertebral column, ASSESS from BACK), OVARIES, UTERUS Hollow Viscera: -Organs that change shape depending on their contents -*STOMACH, GALLBLADDER, INTESTINES, COLON, BLADDER Vascular Structures:*(listen w/bell) -*Aorta (descends behind PERITONEUM, the serous membrane that forms the lining of abdominal cavity) to 2cm below umbilicus; bifurcates into R&L common iliac arteries. -*Iliac arteries: (the R&L iliac arteries become the femoral arteries in groin area. *Aortic Pulsations: easily palpated. DON'T Palpate if MARKED pulsations (listen w/bell)

Peptic Ulcer Disease - Evidence-Based Practice Box 23-1

Risk Assessment: -H. pylori in GI tract -Excessive ETOH -Use of NSAIDs -Smoking -Serious illnesses -Uncontrolled stress as contribution factor Client Education: -Effective handwashing -Eat foods cooked completely -Take pain meds as directed (dose, w/food, avoid drinking ETOH) -Stop smoking -Take GI med per order

Obj. Data: Inspect Abdominal Contour

Sitting at client's side; look across abdomen, at slightly higher level -Normal flat, rounded or scaphoid in thin adults, evenly rounded -*Generalized protuberant or distended abdomen RT air, obesity, FLUID, organ enlargement, FULL bladder, uterine enlargement, ovarian tumor or cyst (6 FS OF ABDOMINAL DISTENSION P. 503). [MEASURE ABD. GIRTH (TABLE 23-2)] -Scaphoid can be abnormal w/severe weight loss.