Chapter 11: Abdomen & Abdominal Assessment

Describe the procedure for auscultation of bowel sounds

*Use diaphragm and press lightly to skin *Begin in the RLQ at the ileocecal valve area.. listen to all 4 quads *Absent BS- listen for >5 minutes in each quad * Vascular sounds use bell to listen for bruits- aorta, renal, iliac, femoral (ARIF)

Describe palpation of the liver

- Palpate in the RUQ to assess liver borders - Place your left hand behind the back at 11th and 12th rib to lift and support - Place your right hand on the RUQ with fingers parallel to midline - Press deeply down and under right costal margin while patient inhales deeply *Normal to feel liver bump fingertips as diaphragm pushes it down - Hooking (alternative palpation)

Describe the procedure for percussing the liver span

- Percuss downward at the right MCL from resonance to dullness; mark area (5-7th ICS) - Percuss upward at the right MCL from tympany to dullness; mark area - Span usually 6-12 cm

Describe the procedure for percussing the spleen

- Percuss for a dull note from the 9th to 11th ICS behind the left Midaxilary Line - Usually less than 7 cm SPLENIC DULLNESS: - Percuss in the lowest interspace in the left AAL. This should be tympanic - Ask person to take a deep breath, it should remain tympanic - Dullness anterior to the MAL indicates splenomegaly

Describe palpation of the spleen

- Place left hand over patients abdomen behind left side at the 11th and 12th rib, lifting to support - Place right hand on LUQ with fingers pointing to axilla just below rib margin - Push down and under the left costal margin while the patient is breathing deeply * should feel nothing firm

Describe rebound tenderness (blumberg sign)

-Person reports abdominal pain -Choose site away from painful area -Hold hand at 90 degrees and push down slowly and deeply -Lift hand up quickly - A normal response is no pain. Pain= peritoneal inflammation

Describe the procedure and rationale for determining costovertebral angle (CVA) tenderness

-Place hand over 12th rib at the costovertebral angle on the back. -Thump the hand with the ulnar edge of the other first *Pain occurs with inflammation of the kidney or paranephric area

When palpating the abdomen the nurse finds a large pulsating mass. The nurse would suspect this is what?

Abdominal aortic aneurysm Pulsation of the aorta may be increased and lateralized in an abdominal aortic aneurysm. Ascites is collection of fluid in the abdomen. Inflammation and tumors do not pulsate.

Which abdominal finding in an elderly client should prompt a nurse to perform additional assessment to determine the cause?

An enlarged liver felt during palpation The liver normally decreases in size after age 50 years. An enlarged liver needs further assessment. Appetite decreases with age due to altered metabolism, decreased taste sensation, decreased mobility, and possibly depression. Tympany is a normal finding over the stomach. The fluid wave test should be negative unless fluid (ascites) is present in the abdomen.

An emergency department nurse is caring for a teenage client who has severe pain in the umbilical area. Documentation shows that the client exhibits "Rovsing's sign." What might this client's medical diagnosis be?

Appendicitis Rovsing's sign is an indicator of appendicitis. It is not a sign of gastroenteritis, liver disease, or an enlarged spleen.

Chris is a 20-year-old college student who has had abdominal pain for 3 days. It started at his umbilicus and was associated with nausea and vomiting. He was unable to find a comfortable position. Yesterday, the pain became more severe and constant. Now, he hesitates to walk, because any motion makes the pain much worse. It is localized just medial and inferior to his iliac crest on the right. Which of the following is most likely?

Appendicitis This is a classic history for appendicitis. Notice that the pain has changed from visceral to parietal. It is well localized to the right lower quadrant, making appendicitis a strong consideration.

A nurse is teaching a client who suffers from peptic ulcers how to reduce the risk of their recurrence. Which of the following should the nurse recommend?

Avoid excessive alcohol intake The nurse should recommend avoiding excessive alcohol intake, as this is a risk factor associated with peptic ulcer disease. The nurse should also recommend eating foods that have been cooked completely and taking pain medications with food. Antacid medications may relieve peptic ulcers.

While auscultating a client's abdomen, the nurse hears the client's stomach growling. The nurse knows that this is which type of bowel sound?

Borborygmus The nurse should find that bowel sounds are absent in a client with paralytic ileus. Paralytic ileus is a condition characterized by absence of bowel sounds, not normal bowel sounds. Hyperactive bowel sounds may be caused by diarrhea, gastroenteritis, and early bowel obstruction. Hypoactive bowel sounds may be due to surgery or late bowel obstruction. Hyperactive bowel sounds referred to as "borborygmus" may also be heard. These are the loud, prolonged gurgles characteristic of one's "stomach growling." Erratic is not a type of bowel sound.

Select the sequence of techniques used during an examination: a. percussion, inspection, palpation, auscultation b. inspection, palpation, percussion, auscultation c. inspection, auscultation, percussion, palpation d. auscultation, inspection, palpation, percussion

C. Inspection, auscultation, percussion, palpation

Discuss inspection of the abdomen, including findings that should be noted

Contour: Flat, Scaphoid, Rounded, Protuberant [nutritional state] Symmetry: No budges, masses (hernia) Umbilicus: Midline, inverted, no discoloration, inflammation Skin: smooth, even, possible striae (recent=pink or blue) Pulsation: may see aorta pulsate Hair Distribution: pubic hair male (diamond shape) female (inverted triangle) Demeanor: benign facial expression, relaxed

A nurse is instructing a client who suffers from peptic ulcer disease about the causes of this condition. Which of the following should the nurse mention as a common bacterial cause?

Helicobacter pylori

Differentiate the following abdominal sounds: normal, hyperactive, and hypoactive bowel sounds, succession splash, bruit

Hyperactive: Loud, high pitched, rushing, tinkling, gurgling sounds, "borborygmi," signal increased motility. They occur with early mechanical bowel obstruction, gastroenteritis, brisk diarrhea, laxative use, and subsiding paralytic ileus Hypoactive: Diminished or absent bowel sounds signal decreased motility as a result of inflammation as seen with peritonitis, pneumonia, surgery or late bowel obstruction Succession splash: Unrelated to peristalsis, this is a very loud splash auscultated over the upper abdomen when the infant is rocked side to side. It indicates increased air and fluid in the stomach, as seen with pyloric obstruction or large hiatus hernia

A 21-year-old receptionist comes to the clinic reporting frequent diarrhea. She states that the stools are very loose and there is some cramping beforehand. She states this has occurred on and off since she was in high school. She denies any nausea, vomiting, or blood in her stool. Occasionally she has periods of constipation but that is rare. She thinks the diarrhea is much worse when she is nervous. Her past medical history is not significant. She is single and a university student majoring in accounting. She smokes when she drinks alcohol but denies any illegal drugs. Both of her parents are healthy. Her entire physical examination is unremarkable. What cause of diarrhea is the most likely etiology?

Irritable bowel syndrome Irritable bowel syndrome will cause loose bowel movements with cramps, but no systemic symptoms of fever, weight loss, or malaise. This syndrome is more likely found in young women with alternating symptoms of loose stools and constipation. Stress usually makes the symptoms worse as well as certain foods.

Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with fairly significant left upper quadrant pain. On examination of this area a rough grating noise is heard. What is this sound?

It is a splenic rub. A rough, grating noise over this area represents a splenic rub, which can accompany splenic infarction. Rubs also occur over the liver and pleura and pericardium.

Describe the proper positioning and preparation of the patient for the examination

Light: Use a strong overhead light & secondary stand light Drape: Genitalia and female breasts Position for abdominal wall relaxation: * Emptied Bladder * Warm room * Supine with head on pillow, knees bent,State arms at side or across chest * Examine painful areas last

Light vs. Deep Palpation

Light: depress skin about 1 cm. Form an overall impression of the skin surface and superficial musculature. Voluntary muscle guarding vs. involuntary rigidity. Deep: depress skin 5-8cm. Note location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses.

A nurse is inspecting the abdomen of a young, fit client who has well-defined abdominal muscles. The nurse recognizes the vertical line that appears in the center of the client's abdomen as which of the following?

Linea alba

A nurse performs percussion by placing the left hand flat against the client's lower rib cage and striking it with the ulnar side of the right fist. The client reports tenderness. The nurse recognizes this as an abnormal finding for which organ?

Liver Percussion for liver tenderness is elicited by placing the left hand flat against the lower rib cage and striking it with the ulnar side of the right fist. The costovertebral angles are located at the twelfth rib posteriorly. Tenderness of the costovertebral angles indicates a kidney problem such as infection (pyelonephritis), renal calculi, or hydronephrosis. Percussion of the spleen begins in the left midaxillary line and progresses downward until the sound changes from lung resonance to splenic dullness. The gall bladder is not percussed.

Name the organs that are normally palpable in the abdomen

Liver, Spleen, Kidneys, (Aorta)

The linea alba is located where?

Middle of the ventral abdominal wall

List 4 conditions that may alter normal percussion notes

Obesity: Tympany. Scattered dullness over adipose tissue Air or Gas: Tympany over large area Ascites: Tympany at top where intestines float. Dull over fluid. Ovarian Cyst (large): Top dull over fluid. Intestines pushed superiorly.

State the rationale for performing auscultation of the abdomen before palpation or percussion

Palpation and percussion can increase peristalsis, which would give a false interpretation of bowel sounds

What precaution should the nurse take when measuring a client's abdominal girth to screen for cardiovascular risk factors?

Place the tape measure behind the client and measure at the umbilicus The nurse should place the tape measure behind the client and measure at the umbilicus. The umbilicus should be the starting point when measuring the abdomen especially when distention is apparent. Abdominal measurement is generally taken in the morning after voiding, not after the client has had a full meal. The ideal position to measure the abdomen is standing not sitting. The nurse informs the client that the pen mark on the abdomen should not be washed out only if the client is being monitored on a regular basis to determine progress of treatment for abdominal distention.

The client would complain of pain in what quadrant if experiencing appendicitis?

RLQ With appendicitis, the client would experience pain in the RLQ.

The nurse correctly identifies the gallbladder is located where?

RUQ

Which nursing diagnosis is most appropriate for an elderly client with poor dentition?

Risk for Imbalanced Nutrition: Less Than Body Requirements A client with poor dentition is at risk for Imbalanced Nutrition: Less Than Body Requirements as teeth may be missing or chewing may be difficult. None of the other diagnosis are related to poor dentition

The nurse is caring for a client suffering from a nutritional deficiency. The nurse expects that the client has a dysfunction of which abdominal body part?

Small intestine Absorption of nutrients takes place almost exclusively in the small intestine. The esophagus propels the food bolus by means of slow peristaltic movements into the stomach. The descending colon is part of the large intestine. Mastication occurs in the mouth, then food moves into the oropharynx and esophagus for food propulsion through the digestive tract.

Which organ that resides in the abdominal cavity stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes?

Spleen The spleen resides in the abdominal cavity and stores red blood cells and platelets, produces new red blood cells and macrophages, and activates B and T lymphocytes. The pancreas resides in the abdominal cavity and is an endocrine gland producing several important hormones, including insulin. The gallbladder, also located in the abdominal cavity, stores bile before it is released into the small intestine. The liver, an organ also located in the abdominal cavity, has a variety of functions to include detoxification, protein synthesis, and the production of biochemical used in the digestion process.

When inspecting the abdomen, which of the following client positions facilitates correct examination technique?

Supine with arms at sides or folded across chest A supine position with pillows under the client's head and knees is most conducive to accurate examination and is preferable to a sitting, Trendelenberg, or semi-Fowler's position.

Which of the following statements provides the most accurate guide to the assessment of the gallbladder?

The gallbladder is deep to the liver and cannot normally be distinguished from the liver clinically Because the gallbladder is deep to the liver, it is normally not amenable to direct examination by auscultation, palpation, or percussion. This does not mean, however, that cholecystitis and cholelithiasis cannot be assessed for a thorough history. The gallbladder and the spleen are not proximate.

What is the predominate sound that should be heard during the abdominal assessment?

Tympany

ID and give the rationale for each of the percussion notes heard over the abdomen

Tympany: Should predominate because air in the intestines rises to the surface when the person is supine Dullness: Over a distended bladder, adipose tissue, fluid or a mass Hyperresonance: Present with gaseous distention

Rigidity vs. voluntary guarding

Voluntary guarding: Person is cold, tense, or ticklish. Bilateral and will feel the muscles relax slightly during exhalation Involuntary rigidity: Constant, board-like hardness of the muscles. Unilateral. Painful in localized area when person attempts a sit-up.

During the health history, a client who has abdominal pain reports having occasional nausea and diarrhea. In which section of the health history should the nurse document this finding?

associated manifestations The nurse should document this finding in the associated manifestations section because this is a report on the experience of other symptoms associated with abdominal pain. In relieving factors, the nurse explores factors that aggravate or relieve the pain. In characteristic symptoms, the nurse should ask the client to describe the pain in his or her own words. Onset refers to when the abdominal pain started.

The nurse is taking the health history of a client who takes a calcium channel blocking medication for hypertension. The client reports a sensation of incomplete evacuation when having a bowel movement about three times per week. For which problem should the nurse further assess the client?

constipation Clients with constipation have 25% or more defecations with either straining or a sensation of incomplete evacuation per week. Sigmoid colon lesions are characterized by thin, pencil-like stools due to an obstructing "apple-core" lesion in this area of the bowel. A clostridium difficile infection is characterized by diarrhea and should be suspected if the client has recently been hospitalized. Pancreatic insufficiency should be further investigated if the client reports having oily or greasy stools.

The sigmoid colon is located in this area of the abdomen: the

left lower quadrant. The left lower quadrant (LLQ) contains the left kidney (lower pole), left ovary and tube, left ureter, left spermatic cord, and descending and sigmoid colon

A nurse assesses a client who reports abdominal pain. Which technique should the nurse use during the physical examination to detect tenderness?

light palpation Light palpation aids in the detection of abdominal tenderness by allowing palpation without aggravating pain. Deep palpation requires that the nurse press down 5 to 8 cm (2 to 3 inches) which may cause the client further discomfort or pain. Deep palpation is warranted to delineate edges of abdominal organ masses. Percussion helps to assess the amount of gas throughout the abdominal visera and masses that are solid or fluid filled. Auscultation allows the nurse to listen for bowel sounds.

While assessing an adult client's abdomen, the nurse observes that the client's umbilicus is deviated to the left. The nurse should refer the client to a physician for possible

masses. A deviated umbilicus may be caused by pressure from a mass, enlarged organs, hernia, fluid, or scar tissue.

A client's abdominal muscles are tense when lying supine for an abdominal assessment. What should the nurse do to ensure the client's comfort during the assessment?

place a small pillow under the client's knees A small pillow placed under the knees relaxes the abdominal musculature. The abdominal assessment should not be performed with the head of the bed raised to a 30-degree angle or sitting with the legs dangling. Removing a pillow from behind the client's head will make the abdominal muscles more tense.

Diagnostic tests completed validate that a client has an obstruction of the ascending and transverse colon. Where should the nurse assess for bowel sounds around the obstruction?

right upper quadrant The right upper quadrant is used to assess for the ascending and transverse colon. The left upper quadrant is used to assess the transverse and descending colon. The left lower quadrant is used to assess the descending and sigmoid colon. The right lower quadrant is used to assess the ascending colon.

During an assessment, the patient describes vomiting moderate amounts that "smell like poop." The nurse might suspect

small bowel obstruction

A client visits the clinic because she experienced bright hematemesis yesterday. The nurse should refer the client to a physician because this symptom is indicative of

stomach ulcers. Vomiting with blood (hematemesis) is seen with esophageal varices or duodenal ulcers.