Chapter 23 Abdominal
Which change in auscultation of bowel sounds should the nurse recognize as most diagnostic of an intestinal obstruction?
An increase in the pitch
left iliac region
initial part of sigmoid colon, lower left region
left hypochondriac region
left upper region below the rib cartilage; diaphragm, spleen
right iliac region
lower right region; cecum, appendix inguinal region
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.
GERD Teaching
- Avoid fatty, fried, citrus, spicy foods, and caffeine. - Eat small meals. Remain upright. - Avoid tight-fitting clothes. - Wt loss. - Quit smoking. - Reduce alcohol intake. - Elevate HPB Avoid alcohol, eat small meals, lose weight, avoid foods that increase reflux, remain upright for 2 hours after eating
peptic ulcer symptoms
-Burning, gnawing, cramping stomach pain especially when empty, between meals, and in early AM. -Pain is midline, in epigastrum, may radiate to costal margins, into the back and rarely to right shoulder -Pain is usually relieved by food and/or antacids include chest pain, fatigue, weight loss, black or tarry stools, and vomiting, which may be bloody.
Inguinal hernia
: the intestine or bladder protrudes through the abdominal wall or into the inguinal canal in the groin
fluid wave test
A second test special technique to detect ascites is the fluid wave test. The client should remain supine. Place the ulnar side of the hand and the lateral side of the forearm firmly along the midline of the abdomen. Place the palmar surface of your fingers and hand against one side of the client's abdomen. Movement of a fluid wave against the resting hand suggests large amounts of fluid are present...ascites is positive which is abnormal. Follow up with ultrasound.
Hernia
A weak spot in the intestinal wall and muscle where an organ or fatty tissue squeezes through There are different types of hernia: Inguinal incisional umbilical hiatal
The nurse suspects an abdominal aortic aneurysm when what is assessed?
Abdominal bruit
abnormal sounds in abd
Air outside of the stomach or intestines is abnormal, on an x-ray it is called free air and is surgical issue Ascites: fluid build up caused by accumulation of fluid in the peritoneal cavity often related to liver disease
The nurse would assess for positive Blumberg sign how?
Applying and releasing pressure to the abdomen
Psoas sign
Ask the client to lie on the left side. Hyperextend the client's right leg. Pain in the RLQ is associated with irritation of the iliopsoas muscle due to appendicitis.
The client presents at the clinic with a chief complaint of pain in her upper abdomen. On assessment the nurse notes that the client has recurrent pain, more than two times weekly, in her upper abdomen, and that this recurrent pain started 2 months ago. What term should the nurse use for this type of pain?
Dyspepsia
Specialty tests
Blumberg sign Murphy sign Psoas sign Obturator sign Shifting dullness/fluid wave test
When conducting the physical examination of a client's abdomen, the nurse auscultates 20 clicks and gurgles over 1 minute. Which of the following statements would accurately describe this finding?
Bowel sounds normal.
The nurse is auscultating the abdomen and notes a swishing sound in the abdominal area. The nurse would document this sounds as a what?
Bruit
During an abdominal examination, a nurse in a provider's office determines that a client has abdominal distention. The protrusion is at the midline, the skin over the area is taut, and the nurse notes no involvement of the flanks. Which of the following possible causes of distention should the nurse suspect?
C.Flatus
abdominal pain question
COLDSPA Character: Describe the pain Onset: When did it begin? Location: Point to the area Duration: How long does the pain last? Severity: How bad is the pain? Pattern: When does it occur? Associated factors: Any other symptoms? (Nausea/vomiting/diarrhea)
Abdomen pain characteristics
Character: Dull/ache, burning, gnawing, pressure, colicky, sharp, knife-like, stabbing, throbbing, variable Onset: When does the pain begin? Onset of pain is a diagnostic clue to its origin. Think of acid reflex: pain in the esophagus may occur after eating. Pain related to gastric ulcers may occur when the stomach is empty. Associated Symptoms: Is there other symptoms associated with the pain? Nausea, vomiting, diarrhea, constipation, gas, fever, weight loss, fatigue, or yellowing of the eyes or skin? Relationship factors: What seems to bring on the pain? What makes it worse? What makes it better? Urine characteristics: dark urine Medications: Medications may produce side effects that adversely affect the GI tract.
Inspection of the abdomen
Color Contour Striae Scars Lesions/rashes Umbilicus Aortic pulsations Symmetry
Teaching for Peptic Ulcers
Cook foods completely, monitor NSAID intake, take meds with food, avoid excessive alcohol, stop smoking Ulcers also cause a feeling of fullness that leads to reduced fluid and food intake, hunger, an empty feeling 1 to 3 hours after a meal, or mild nausea. Symptoms may come and go over days or weeks.
A client complains of abdominal pain with cramping diarrhea, nausea, vomiting, weight loss, and loss of energy. The nurse should suspect which of the following as the underlying cause?
Crohn's disease
On inspection of the abdomen, a nurse notes that the client's skin appears pale and taut. The nurse recognizes that this finding is most likely due to what process occurring within the abdominal cavity?
Fluid accumulation
A client complains of epigastric pain and tarry stools. The nurse should suspect which of the following as the underlying cause?
Gastric ulcer
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
Collecting objective data
Inspection Auscultation Percussion Palpation
Palpation surface
Light palpation to identify areas of tenderness; 4 fingers in circular motion - forming an overall impression of skin. abd deep areas: Normal is non-tender and soft and no guarding. Abnormal: Involuntary reflex guarding. Severe tenderness or pain may relate to trauma, peritonitis, infection, tumors, or enlarged or diseased organs
right hypochondriac region
Liver, Gallbladder, Right Kidney, Small Intestine
Hyperactive bowel sounds
Loud, gurgling sounds, "borborygmi," signal increased motility. They occur with early mechanical bowel obstruction (high-pitched), gastroenteritis, brisk diarrhea, laxative use, and subsiding paralytic ileus. is abnormal is above 30/minute
Perform light and deep palpation
Masses Aorta Liver Spleen Kidneys Bladder
Risk factors for Peptic ulcer
NSAIDS, smoking or chewing tobacco, alcohol, stress, family history, Helicobacter pylori
GERD risk factors
Obesity, hiatal hernia, smoking, dry mouth, asthma, diabetes, delayed stomach emptying, pregnancy, alcohol
Murphy sign-
Press your fingertips under the liver border at the right costal margin and ask the client to inhale deeply. Normal finding: No increase in pain. Abnormal: accentuated sharp pain that causes the client to hold their breath. pain with inflammation of the gallbladder
Quadrants of the abdomen
RUQ, LUQ, RLQ, LLQ
Older Considerations
Salivation decreases Esophageal emptying is delayed Gastric acid secretions decrease Incidence of gallstones increases with age Liver size decreases by 25% between age 20-70, liver function remains normal for most Impaired drug metabolism due to decreased blood flow through the liver Decline in appetite from various factors such as altered metabolism, decreased taste sensation, decreased mobility and possibly depression Constipation- reduced stool frequency (less than 3 BM's per week), straining, lumpy or hard stool, feeling of incomplete evacuation. Impaction - complete blockage by hard, desiccated immovable stool in the rectum, can be life threatening
When inspecting the abdomen, which of the following client positions facilitates correct examination technique?
Supine with arms at sides or folded across chest
Causes of hypoactive BS
paralytic ileus, late bowel obstruction, surgery No bowel sounds: absence of bowel motility could need an immediate referral: paralytic ileus or possible obstruction
Umbilical hernia
part of the small intestine passes through the abdominal wall near the navel
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.
Normal sounds in Abd
There is supposed to be air in the stomach which creates a tympany (drum-like percussion).
Auscultation
Using the diaphragm, begin in the RLQ and proceed clockwise covering all quadrants. bowel sounds occur every 5-15 seconds. Normal is a rate of 5-30 per minute
Obturator Test
also used when acute appendicitis is suspected. Right leg is flexed 90 degrees, examiner immobilizes the right ankle with the right hand, left hand rotates the right hip pulling the right knew laterally (external rotation) and medially (internal rotation). Pain in the RLQ indicates irritation of the obturator muscle due to appendicitis or a perforated appendix.
Hypoactive bowel sounds:
below 5 per minute and absent is no bowel sounds. You need to listen for 5 minutes before determining that there are no bowel sounds
Causes of hyperactive BS
early bowel obstruction, gastroenteritis, diarrhea
Shifting Dullness
if you suspect the client has ascites because of a distended abdomen or bulging flanks, perform this special percussion technique by percussing the flanks from the bed upward toward the umbilicus. If ascites is present and the client is supine, the fluid assumes a dependent position and produces a dull percussion tone around the flanks. Air rises to the top and tympany is percussed around the umbilicus
Collecting subject data on Abdominal
indigestion nausea/ vomiting appetite bowel elimination surgeries family history medications alcohol use stress
hypogastric region
inferior to the umbilical region; encompasses the pubic area
Hiatal Hernia
protrusion of a part of the stomach upward through the opening in the diaphragm
Blumberg's sign
rebound tenderness. Rebound tenderness is assess by palpating deeply at 90 degrees into the abdomen halfway between the umbilicus and the anterior iliac crest. Abnormal is tenderness is sharp, stabbing pain as the examiner releases pressure from the abdomen...could suggest appendicitis
umbilical region
region of the navel or umbilicus
right lumbar region
right middle region near the waist; ascending colon of large intestine
To percuss the liver of an adult client, the nurse should begin the abdominal assessment at the client's
right upper quadrant.
vascular sounds
should be absent -note presence of any vascular sounds or bruits -listen with bell, use firmer pressure, check over aorta, renal arteries, iliac, and femoral arteries, especially in people with hypertension
epigastric region
superior to the umbilical region, generally above the stomach
Palpate: liver, spleen
the liver, spleen (hook Technique is an option), liver under the rt costal margin push up, spleen same but left. - breath in and blow out then push and palpate. Hook technique: Stand to the right of the client's chest. Curl (hook) the fingers of both hands over the edge of the right costal margin. Ask the client to take a deep breath and gently but firmly pull inward and upward with your fingers.
During a physical examination of an adult client, the nurse is preparing to auscultate the client's abdomen. The nurse should
use the diaphragm of the stethoscope.
Incisional hernia
where the abdominal wall pushes through at a site of abdominal surgery
Bowel elimination
•Constipation & diarrhea •Changes in bowel patterns •Decrease in frequency of bowel movements •Increase in frequency of bowel movements •Formed vs. unformed or liquid •Travel history •Medications Diet •Fecal incontinence •Character •Associated symptoms •Related factors Medications
GERD
•Gastroesophageal reflux disease •Stomach acid or contents flow back into the esophagus which can cause irritation and lead to esophagus narrowing, Barrett esophagus (precancerous changes), or an ulcer
abnormal findings for ABD
•Obstruction: high pitched bowel sounds •Absent bowel sounds: peritonitis or paralytic ileus •Ileus: lack of intestinal activity which causes gas, fluids and the contents of the intestines to build up •Obesity: extra fat cells •Ascites: Fluid build-up in the peritoneal cavity •Ovarian Cyst: •Feces: abnormal mass palpated in the abdomen •Hernia: weak spot in the abdominal wall or stomach
peptic Ulcer
•Open ulcers/open sores that form in the lining of the esophagus, stomach, or small intestine •Acid eats away the protective mucous covering & erodes the underlying lining of these organs •Painful(which can be felt anywhere between the sternum and navel, can cause a burning sensation that often wakes the client in the night, and is worse on an empty stomach (often temporarily relieved with acid-reducing medications or some foods).
Percussion
•Percuss for tone •Percuss the span or height of the liver •Percuss the spleen •Perform blunt percussion on the liver and the kidneys •Shifting dullness test: Used to assess for ascites
Nursing considerations upon preparation of the abdominal assessment
•Pt. empty bladder •Warm room •Patient supine, with pillow under head •Stethoscope warm •Painful areas last to avoid muscle guarding •Use distractions to limit abdominal guarding
