GI/GU Health Assessment exam #3
what are abnormal bowel sounds?
absent hypoactive hyperactive
Which structure is located in the right lower quadrant of the abdomen?
Appendix
The nurse has completed the inspection of the patient's abdomen during the physical examination. Which technique will the nurse use next during this examination?
Auscultation
pulsations
aorta
Right upper Quadrant (RUQ) ADGKLPTU
ascending colon duodenum gallbladder right kidney liver pancreas (head) transverse colon ureter (right)
order of exam for abdominal assessment
1. Inspect 2. Auscultate 3. Percuss 4. Palpate
OLDCART: vomitting
1. Onset 2. Location 3. Duration 4. Characteristic 5. Associated factors 6. Relieving or aggravating factors 7. Treatment tried
what are subjective history introductory questions for abdominal assessment?
1. change of appetite or diet 2. food intolerances, food allergies 3. 24 hour dietary recall 4. weight changes 5. difficulty swallowing (dysphagia) 6. exposures 7. travel to and from US 8. stressors 9. medications, nausea, elimination
preparation for abdominal physical assessment
1. client in supine position, knee flexed 2. examine painful area last 3. short fingernails 4. client w/ empty bladder and bowel 5. watch facial expressions for discomfort 6. warm environment, hand, stethoscope
abdominal assessment: additional maneuvers
1. palpate in other position besides supine 2. palpate inguinal area for hernia 3. can localize most painful area by having patient breathe in deep and contract abdomen (cough motion) let pt point to most tender spot 4. ticklish patient - track their hand under yours
prevention of urinary incontinence
1. pelvic muscle training 2. pelvic muscle exercises incontinence is not normal
what are the step for liver scratch test?
1. place stethoscope on the liver 2. begin scratching fingernail lightly just below where you expect the liver 3. scratch sound will intestacy over liver; mark 4. scratch above expected liver border and measure distance
abdominal assessment inspectino
1. skin lesion/rashes, scars, striae, color 2. umbilicus (herniation) 3. abdominal contour 4. distension, symmetry, masses 5. motion of internal organs on surface 6. venous patterns, pulsations
what are you feeling during light abdominal palpation?
1. tone, tenderness, surface characteristics 2. masses, enlarged organs 3. pulsations: aorta, femoral 4, inguinal nodes
what is done for auscultation of bowel sounds?
1. use diaphragm in all 4 quadrants normal sounds: 5-34 times per minute
normally palpable structures
1. xiphoid process 2. normal liver edge 3. right kidney, lower pole 4. pulsatile aorta 5. rectus muscles, lateral borders 6. cecum ascending colon 7. sigmoid colon 8. uterus (gravid) 9. full bladder
what is the normal frequency for bowel habits?
2-3 times a day to 3 x a week
what is the normal span for liver?
6-12 cm
what are the common symptoms for gastroenteritis?
nausea/vomiting diarrhea abdominal cramping fever
While examining a patient, the nurse observes abdominal pulsation between xiphoid process and umbilicus. The nurse should decide that these are:
normal abdominal aortic pulsations
light abdominal palpation
one hand, firm palpation over 4 quadrants
Solid viscera
organs that maintain a characteristic shape 1. liver 2. pancreas 3. kidney 4. adrenal glands 5. spleen
hollow viscera
organs whose shape depends on their contents 1. stomach 2. gallbladder 3. colon 4. small intestine 5. bladder
what are two techniques to percuss liver
percussion technique (difficult) liver scratch test (easy)
what does absent bowel sounds mean?
possible obstruction, listen for 5 minutes
Patient complains of dysuria and pain upon direction palpation of the suprapubic region? What else should the nurse assess?
Costovertebral angle tenderness
A victim in a motor vehicle accident arrives at the ER. Upon light palpation, the nurse notes tenderness and an enlarged mass in the left upper quadrant. What is the nurse's next best action?
Do not further palpate the abdomen
A patient is having difficulty with swallowing medications and foods/ the nurse would document that this patient has?
Dysphagia
abdominal assessment history subjective data
GERD visceral dysfunction surgery test and results GI cancer substance abuse: alcohol, opiates, tobacco Family history: GI cancer, colitis, IBS vaccination
Which structure is located in the left lower quadrant of the abdomen?
Sigmoid colon
abdominal assessment: percussion
quadrants first stomach, liver, kidneys, bladder
retroperitoneal
refers to space near the posterior abdominal wall and the peritoneum
hematemesis
blood in vomit
kidney percussion
blunt technique at the costovertebral angle
deep abdominal palpation
both hands, over all for quadrants
an example of incisional hernia
can be found after surgeries
an example of umbilical hernias
can be found on babies
Patient has hypoactive bowel sounds. The nurse knows that a patient cause of hypoactive bowel sounds is
constipation
while obtaining patient pain description, what could be in included/used?
cramping, sharp, dull, knifelike, burning, gnawing - use pain scale
acute bowel obstruction
diffuse abdominal pain with abdominal distention, hyperactive high pitch bowel sounds, tenderness with palpation
During report, the student nurse hears that patient has hepatomegaly and and recognizes that this term refers to:
enlarged liver
protuberant abdomen 6 F's
fat fluid flatus fetus feces fatal growths
what are the different types of contour of abdomen?
flat scaphoid rounded protuberant
what are the possible causes for pain?
food, stress, fatigue, menses, infection
Nausea/vomiting subjective data history
frequency and amount color and odor: blood in vomit relationship to food pregnancy
elimination: bowel habits to consider
frequency, color/consistency, loose stool vs diarrhea, constipation, presence of blood in stool
right upper quadrant or epigastric visceral pain
from billary tree and liver
Hypogastric visceral pain
from colon, bladder, uterus
periumbilical pain visceral pain
from small intestine, appendix, or proximal colon
epigastric visceral pain
from stomach, duodenum, or pancreas
suprapubic or sacral visceral pain
from the rectum
bright red blood in stool
hematochezia
gastroenteritis
inflammation of the GI tract (mouth, esophagus, stomach, and intestines)
acute cholecystitis
inflammation of the gallbladder, RUQ pain and tenderness - hook left thumb of the right hand under the costal margin (lateral border of rectus muscle + costal margin)
review figure 16-1: landmarks of the abdominal wall
locate: rectus abdominis muscle, xiphoid process, iliac crest, symphysis pubis etc
make sure to ask what relieves pain
medication: analgesic, antacids position
tarry stool blood in stool
melena
peritoneum
membrane lining of the walls of the abdominal and pelvic cavities
where are you measuring the liver?
mid clavicular
peristalsis
motion of internal organs on surface
when palpating abdomen, take note of any
rigidity guarding tenderness rebound tenderness: does it hurt more when I press down or let go?
health promotion
screening for alcohol abuse cage classic findings: 1. hepatosplenomegaly 2. ascites 3. caput medusa 4. spider angiomas 5. peripheral edema 6. palmar erythema 7. erythematic or bulbous nose
pain location and radiation
site characteristics referred pain: location not always at site of affected organ
what are you feeling for during deep abdominal palpation?
spleen: avoid if enlarged or if possible injury kidneys: using sandwich technique - L kidney shouldn't feel - R kidney is 1-2 cm lower liver: hook technique
liver percussion technique
start with lung resonance and work down; work up from abdominal sounds until dull and measure distance between
urinary tract health history
suprapubic pain dysuria, urgency, frequency polyuria, nocturia urinary incontience hematuria (gross vs microscopic) kidney or flank pain
protuberant abdomens: ascites
top: tympany, bulging flank, dullness, umbilicus may be protuberant.
what is done for auscultation for vascular bruits?
use bell - listen for aorta, renal arteries, iliac, and femoral
what are the causes for gastroenteritis?
virus, bacteria, parasite, medications, food intolerances