341 Exam 4

Vasculature of abdomen

aorta, left to midline bifurcates 2 cm below unbilicus into left and right common iliac arteries become femoral artery in groin area

midline

aorta, uterus (if enlarged), bladder (if distended)

elbow

articulations of humerus radius and ulna hinge action palpable landmarks: - medial and lateral epicondyles - olecranon process of ulna

rectum

connects to anal canal distal portion of large intestine 4 inches long extends from sigmoid colon - rectusisgmoid junction

musculoskeletal additional hx

infants and children: L and D info (traumatic delivery?) dev. milestones hx of broken bones, trauma and tx presence of bone or spinal deformity adolescent: hx of sports or activities pattern of warm up and exercise use of safety equipment interventions if injury occurs aging adult: functional assessment questrions can elicit any kloss of function, self care deficit or safety risk new onset weakness falls or stumbling mobility devices ** recommend DEXA screening for females above 65 y.o for osteoporosis (measures changes in bone mineral density

Cholecystitis

inflammation of the gallbladder; usually associated with gallstones

prostatitis

inflammation of the prostate gland

musculoskeletal system subjectibe data

joint - pain, stiff, swelling, heat, red - limitation in movement muscles - pain or cramping (myalgia, intermittent claudication) - weakness bones - pain, deformity, accidents or trauma (fractures, sprains, dislocations functional assess - limits in ADLs? self care behaviors - occupational hazards - exercise diet - meds -cigarretes, alc

sphincters

keep canal closed but allow passage of gas and feces internal - under involuntary control by autonomic NS external is voluntary control

diastasis recti

midline longitudinal ridge in the abdomen, a separation of abdominal rectus muscles

Aortic aneurysm, abdominal

most are located below renal arteries pulsating mass in upper abd left to midline

adolescent additional abd hx

eating disorders more common extremly thin indicates anorexia nervosa dietary pattern exercise pattern weight changes/ how was it lost impact on activity and body changes impact on peers or family

enlarged kidney

enlarged with hydronephrosis, cyst, or neoplasm -kidneys never have sharp edges -the kidney has no palpable notch -percussion over the kidney is tympanitic b/c of the overriding bowel

aging adult abd considerations

fat in suprapubic area, changes in fat distribution, decrease in estrogen decreased taste and salivation decreased esophageal emptying, increase aspiration risk decreased gastric acid production gallstones relaxed musculature decrease in liver size by 25% = decrease in drug metabolism constipation (under 3 BM per week) ; not physiological change, caused by lifestyle changes

5 F's: higher risk of abdominal abnormalities

female fat forty (age) fertile flatulent

developmental considerations for anus, rectum and prostate

first newborn stool is dark green and marks anal patency voluntary control of anal sphincter does not occur until nerve ending are fully myelinized (1.5-2 yo) prostate 2x the size in puberty and enlarges in middle adult years benign prostate hyperplasia (BPH) = 80% men over 60

polyp

growth extending from the surface of mucous membrane

culture and genetics: anus rectum and prostate

prostate cancer: most frequent diagnosed cancer in men higher risk in black and black carribean colorectal cancer: higher rate in alaska natives and black 30-40% higher risk in men

wrist and carpals

radiocarpal joint: articulation of distal radius and carpal bones midcarpal joint: articulation between 2 parallel rows of carpals metacarpophalangeal joints: knuckles interphalangeal joints: DIP (fingertips) and PIP

Blumberg's sign

rebound tenderness - appendicitis occuring in RLQ when pressure applied to LLQ site should be remote from area that pt reported pain with palpation hold hand at 90 degrees push down slowly and deeply and lift quickly negative = no pain positive = pain when lifted sign of peritoneal inflammation that accompanies appendicitis

rectal prolapse

rectal walls have prolapsed and can be seen outside of the body

anal canal

region, containing two sphincters, through which feces are expelled from the body GI tract outlet many sensory nerves

Anus, Rectum and Prostate Subjective Data

• Discuss the patient's usual bowel routine - dyschezia = pain due to local condition (hemorroid or fissure) and constipation • Any changes in bowel habits • Rectal bleeding or blood in the stool - melena - steatorrhea - fat in stool - flatulence • Medications - laxative, stool softener, iron, enemas • Rectal conditions - hemorrhoids = pruritis and painless bleeding - fissure fistula fetal incontinence • Family history self-care behaviors, such as a high fiber diet and colorectal cancer screening • Blood in stool- bright red or dark and tarry (melena) clay colored stool - absent bile pigment

ankle and foot

*tibiotalar joint* articulation of tibia, fibula, and talus *hinge joint* limited to flexion (dorsiflexion) and extension (plan tar flexion) in one plane *landmarks are two bony prominences on either side*-medial malleolus and the lateral malleolus -strong, tight medial and lateral ligaments extend from each malleolus onto foot to help lateral stability of ankle -may be torn in eversion or inversion sprains of ankle *joints distal to ankle give additional mobility to foot* -subtalar joint permits inversion and eversion of foot -foot has longitudinal arch, with weight-bearing distributed between parts that touch ground, the heads of metatarsals and calcaneus (heel)

PICA

an abnormal craving or appetite for nonfood substances, such as dirt, paint, or clay that lasts for at least 1 month toddler may attempt to eat nonfoods but should recognize edibles by age 2

measures to enhance abdominal wall relaxation

-Empty bladder -Warm room, hands, & stethoscope and short nails -Supine, head on pillow, knees bent or on pillow and arms at side or across chest -Breathing exercises, your soothing voice, have the patient tell abdominal history while you palpate examine painful areas last

Abdominal Subjective Data

1. Appetite changes in appetite or wright anorexia 2. Dysphagia occurs w disorders of throat and esophagus 3. Food intolerance lactose intolerant allergies pyrosis (heartburn) 4. Abdominal pain visceral or parietal (inflammation of peritoneum) or referred 5. Nausea/vomiting hematemisis 6. Bowel habits frequency, color, consistency 7. Past abdominal history 8. Medications also alc and cigarretes use 9. Nutritional assessment

Order of abdominal assessment

1. Inspection 2. Auscultation 3. Percussion 4. Palpation auscultation before percussion and palpation because they can elicit peristalsis and BS

Four Layers of Abdominal Muscles

1. outer= rectus abdominis 2. external abdominal obliques 3. internal abdominal obliques 4. transverse abdominis joined by tinea alba at midline

incisional hernia

A bulge near an old operative scar that may not show when person is supine but is apparent when the person increases intra-abdominal pressure by a sit-up, by standing, or by the Valsalva maneuver.

pilonidal cyst

A cyst near or on the natal cleft of the buttocks that often contains hair and skin debris.

protuberant abdomen

Abdominal distention pregnancy or beer belly

knee

Articulation of femur, tibia, and patella hinge suprapatellar pouch = bursa above patella up to 6cm medial and lateral menisci (wedge shaped cartilage that cushion tibia and femur anteriorly and posteriorly stabilized by cruciate ligaments (criss cross in knee) medial and lateral stabilized by collateral ligaments prepatellar bursa (between patella and skin/ prevent friction infrapatellar pad below patella quadricep muscle located on anterior and lateral thigh - extends knee tibial tuberosity at midline

BPH (benign prostatic hyperplasia)

Age-associated prostate gland enlargement that can cause urination difficulty.

enlarged nodular liver

An enlarged and nodular liver occurs with late portal cirrhosis, metastatic cancer, or tertiary syphilis.

enlarged liver

An enlarged, smooth, nontender liver occurs with fatty infiltration, portal obstruction or cirrhosis, high obstruction of inferior vena cava, and lymphocytic leukemia. The liver feels enlarged and smooth but is tender to palpation with early heart failure, acute hepatitis, or hepatic abscess.

Enlarged Gallbladder

An enlarged, tender gallbladder suggests acute cholecystitis. Feel it behind the liver border as a smooth and firm mass like a sausage, although it may be difficult to palpate because of involuntary rigidity of abdominal muscles. The area is exquisitely painful to fist percussion, and inspiratory arrest (Murphy sign) is present. An enlarged, nontender gallbladder also feels like a smooth, sausagelike mass. It occurs when the gallbladder is filled with stones, as with common bile duct obstruction.

temporomandibular joint (TMJ)

Articulation of mandible and temporal bone Can feel it in depression anterior to tragus of ear TMJ permits jaw function of speaking and chewing Allows three motions: Hinge action to open and close jaws Gliding action for protrusion and retraction Gliding for side-to-side movement of lower jaw

enlarged spleen

Because any enlargement superiorly is stopped by the diaphragm, the spleen enlarges down and to the midline. acute infections = it is moderately enlarged and soft, with rounded edges. When the result of a chronic cause, the enlargement is firm or hard, with sharp edges.

components of musculoskeletal system

Bones Joints - articulation - permit mobility - fibrous = immoveable (skull sutures) - cartilaginous = slightly moveable (vertebrae) - synovial = freely moveable Muscles - 40-50 percent body weight - skeletal under voluntary control (contraction) - tendons connect to bone Cartilage Ligaments - fibrous bands between bones, prevent undesirable movement Bursa - enclosed fluid filled sac located in areas of potential friction knee elbow

spine

C 7 and T 1 spinous process most prominent at neck base inferior angle of scapula normally at interspace between t 7 and t8 imaginary line connecting highest pt on each iliac crest crosses L 4 imaginary line joining 2 symmetric dimples that overlie posterior superior iliac spine cross sacrum lateral view = double s curve = four curves cervical and lumbar = concave thoracic and sacrococcygeal = convex

"Linea Nigra" of pregnancy

Dark line of hyperpigmentation on the abdomen

common causes of constipation

Decreased physical activity Inadequate intake of water Low-fiber diet Side effects of medications Irritable bowel syndrome Bowel obstruction Hypothyroidism Inadequate toilet facilities inadeqaute toileting facilities difficuly ambulating to toilet

7 F's of abdominal distention

Fat Flatus Fluid Fetus Feces Full bladder Fibroid cyst -- ovarian [Fatal tumor]

musculoskeletal movements

Flexion - bending limb at joint Extension - straightening Abduction Adduction Pronation - palm down Supination - palm up Circumduction - arms in circle around shoulder Inversion - sole of foot inward at ankle Eversion - sole of foot outward Rotation protraction - moving forward parallel to ground retraction - moving backward elevation depression

Percussion of abdomen

Goal is tympany assessing relative density of abd contents and screening for abn fluid or massess yields high variability of results (generally not recommended) general tympany: percuss lightly in all four quads to determine prevailing amount of tympany and dullness in clockwise manner tympany should be predominant dullness = distended bladder, adipose tissue, fluid or mass hypertympany = gaseous distenstion

percussion of the costovertebral angle

Lloyd's test/sign to check for kidney pain/stones place one hand over 12th rib at costovertebral angle on back thumnb hand with ulnar edge of other fist should be no pain sharp pain occurs with inflammation of kidney

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.

fissure

Narrow, slitlike opening

Left Lower Quadrant (LLQ)

Part of descending colon Sigmoid colon Left ovary and tube Left ureter Left spermatic cord

epigastric hernia

Protrusion of abdominal structures presents as a small, fatty nodule at epigastrium in midline, through the linea alba. Usually one can feel it rather than observe it. May be palpable only when standing.

hernia

Protrusion of an organ through the wall of the cavity that normally contains it

Right Lower Quadrant (RLQ)

cecum, appendix, right ovary and tube, right ureter, right spermatic cord

viscera

The internal organs of the body

abdominal physical exam prep

adequate lighting expose abd so fully visible drape genitals and breasts

pruritus ani

a common chronic condition of itching of the skin around the anus

guaiac test

a diagnostic test looking for occult blood in the stool. It is done after taking a small stool sample during a rectal examination

fecal impaction

a mass of dry, hard stool that remains packed in the rectum and cannot be expelled

specific lab and diagnostic tests : abdomen

abd x ray ultrasound colonoscopy, sigmoioscopy, endoscopy barium enema blood breath urine gastric and renal tests: - kidney and liver function - H. pylori - urine analysis - culture and sensitivity - culture gram pos and neg -gastric or fecal gualc test

fistula

abnormal passageway between two organs or between an internal organ and the body surface

scaphoid abdominal contour

abnormally sunken abdominal wall, as with malnutrition or underweight

anorectal fistula

abscess that tunnels to the skin surface from the anus or rectum

additional abd hx for aging adult

access to groceries and food prep shared meals or eating aline 24 hour diet recall (may not be sufficient) swallowing or eating difficulty activities following meals (walk, nap) bowel health (frequency, constipation, fiber, liquids, use of laxatives) meds

fluid wave test of abdomen (percussion)

ascites = free fluid in peritoneal cavity (HF, portal HPN, cirrhosis, hepatitis, pacreatitis, cancer) differentiate from gaseous distention stand on pt right side place ulnar surface of pt own hand firmly on midline place your left hand on pt right flank with right hand reach across abd and give left flank a firm strike if ascites is present a fluid wave will generate and you will feel a distinct tap on left hand if its gaseous distention there will be no tap look for presence of leg edema as well

Striae

atrophic pink, purple, or white linear streaks on the breasts, associated with pregnancy, excessive weight gain, or rapid growth during adolescence

Light/Deep palpation of the abdomen

begin with light then proceed to deep light four fingers close together, depress skin 1 cm gentle rotary motion, moving clockwise around abd form an overal impression of skin surface and superficial musculature note muscle guarding, rigidity, large masses or tenderness deep: push 5-8 cm (2-3in) may use bimanual technique (2 hands ) note location, size, consistency, mobility, of any palpable organs any enlargement, tenderness or massess is the mass normal palpable or an enlarged organ?

additional abd hx for infants and children

breat or bottle feeding tolerating new foods what foods have been introduced eating pattern PICA elimination pattern constipation abd pain or gas overweight (onset age, diet pattern, decrease in physical activiity, family hx)

Inspect abdomen

countor: stand on right side and look down on abd determine profile from rib margin to pubic pone contour describes nutritional state and ranges from flat to round ; scaphoid vs protuberant symmetry: should be symmetric bilaterally note any buldges, mass or asymmetry hernia patient taking deep breathe would highlight abn umbilicus: midline and inverted with no discoloration, inflammation or hernia everted could mean ascites or underlying mass, pregnancy deeply sunken = obesity skin: smooth and even skin turgor any pigment change or lesions or scars striae = silvery white linear marks occur when elastic fibers are broken after stretching pulsation/movement: normally may see pulsations from aorta beneath skin in epigastric area thin pt with good muscle relaxation marked aorta pulsation = widened pulse pressure marked visible peristalsis in combo w distended abd = intenstinal obstruction hair distribution: pattern of pubic hair is diamond shaped in men and inverted triangle in women demeanor comfy, relaxed, benign facial expression, slow even resp.

hypoactive bowel sounds

diminished or absent bowel sounds signal decreased motility as a result of inflammation as seen with peritonitis; from paralytic ileus as following abdominal surgery; or from late bowel obstruction. Also occurs with pneumonia.

culture and genetics: abdomen

lactose intolerance and celiac disease lactase = digestive enzyme for absorption of lactose lactose intolerant = low levels of lactase abd pain, bloating and flatulence if ingested 20-30% whites, 70% mexican american , 80% black, 100% american indian celiac disease = autoimmune disorder affecting less than 1% population permanantly intolerant to gluten immune mediated inflammation results in damage to small intestine and malabsorption diarrhea, abd pain, distension, anemia, osteoporosis, nueropathy, liver function, skin lesions

prostate gland

lies anterior to wall of rectum and behind oubic bone surrounds ureter 2 lateral lobes seperate by shallow groove called median julcus

anus rectum and prostate exam prep

lighting, lube, gloves, pen light, guaiac place male in left lateral, lithotomy or standing position, male should point toes together and relax muscles female placed in lithotomy if also recieving genital exam

murpheys sign

liver nomal palpation of the liver does not elicit pain patient with cholecystits/inflammation of the gallbladder will have pain holding fingers under liver border, pt takes deep breath positive = sharp pain and inspiratory arrest due to descending liver pushing inflammed gallbladder into finger tips less accurate if patient is above 60 bc 25% dont have tenderness with cholecystitis

Right Upper Quadrant (RUQ)

liver, gallbladder, duodenum, head of pancreas, right kidney and adrenal, hepatic flexure of colon, part of ascending and transverse colon only intestines fill all four quads

noting masses

location size shape consistency (soft, firm, hard) surface (smooth or nodular) mobility (movement w resp) pulsatility tenderness

hyperactive bowel sounds

loud, high-pitched, rushing, tinkling sounds that signal increased motility

lithotomy position

lying on back with legs raised and feet in stirrups

solid viscera

maintain shape liver, pancreas, spleen, adrenal glands, kidneys, ovaries, uterus

PSA test

measurement of levels of prostate-specific antigen (PSA) in the blood

Palpating the liver

murpheys Place your left hand under the person's back parallel to the eleventh and twelfth ribs and lift up to support the abdominal contents. Place your right hand on the RUQ, with fingers parallel to the midline. Push deeply down and under the right costal margin. Ask the person to breathe slowly. With every exhalation, move your palpating hand up 1 or 2 cm. should feel edge of liver bump fingertips as diaphragm pushes down during inhalation firm regular ridge may not be palpable in some patients enlarged liver may be palpated greater than 1-2 cm below right costal margin (record number) could be displaced downward with chronic emphysema (hyperinflated lungs) alternative technique = hooking stand at patient shoulder and swivel body to right so facing pt feet hook fingers under RCM from above and ask pt to take deep breath

palpating spleen

normally the spleen is not palpable -must be enlarged 3 times its normal size to be felt. -reach your left hand over the abdomen and behind the left side at the 11th and 12th ribs -lift up for support -place your right hand obliquely on the LUQ with the fingers pointing toward the left axilla and just inferior to the rib margin -push your hand deeply down and under the left costal margin and ask the person to take a deep breath -you should feel nothing firm - alternative position is to roll the person onto their right side to displace the spleen more forward and downward - palpate same way enlarged spleen = mono, trauma, luekemia, lymphoma, HIV can rupture easiy

Palpation of abdomen

note any muscular resistance, tenderness, enlargement of organs, masses note sze location, consistency of certain organs use comfort measures to ensure relaxation since people are naturally inclined to protect abd ticklish pt: keep persons hand under your own with fingers curled over theirs use stethoscope with fingers around it; people dont see stethoscope as ticklish object voluntary guarding: occurs when pt is cold, tense, ticklish bilateral and interferes with deep palpation if persisting after relaxation measures it prob involuntary (constant hardness accompanying peritoneum inflammation could be unilateral)

auscultating abdominal vascular sounds

note presence of vascular sounds/bruits firmer pressure over aorta, renal arteries, iliac and femoral arteries note location, pitch and timing bruit should not be present

anus rectal and prostate palpation

place pad of index finger at anus, as it relaxes on exhale insert slowly toward umbilicus NEVER approach anus at right angle canal should feel smooth and even polyp migjt be soft and slightly moveable mass

DEXA scan

procedure that measures bone mineral density (BMD) to examine for osteoporosis

shoulder

shoulder girdle = humerus, scapula and clavicle ball and socket joint joint stabilized by four powerful muscles and tendons = rotator cuff SITS muscles supraspinous infraspinous teres minor subscapularis subacromia bursa palpable landmarks: acromion process below is greater tubercle of humerus coracoid process

anal columns (columns of morgargri)

small longitudinal folds in the anal canal run vertically and contains veins and arteries along rectum end at the anorectal junction malformation and conditions of increased venous pressure cause hemorrhoids

umbilical hernia

soft, skin-covered mass, the protrusion of the omentum or intestine through a weakness or incomplete closure in the umbilical ring

hollow viscera

stomach, gallbladder, small intestine, colon, bladder shape depends on contents not usually palpable unless distended

Left Upper Quadrant (LUQ)

stomach, spleen, left lobe of liver, body of pancreas, left kidney and adrenal, splenic flexure of colon, part of transverse and descending colon

five major functions of musculoskeletal system

suppport; standing erect movement encase and protect organs produce wbcs rbcs and platelets in bone marrow reservoir for calcium and phosphorus storage

hemmorrhoids

swollen, twisted, varicose veins in the rectal region

hemorrhoids

swollen, twisted, varicose veins in the rectal region

hip

the articulation between the acetabulum and the head of the femur ball and socket bony landmarks: anterior superior iliac spine, iliac crest ischial tuberosity greater trochanter

borborygmus

the rumbling noise caused by the movement of gas in the intestine stomach growling hyperperistalsis/hyperactive BS

infants and newborns abdomen considerations

umbilical cord is prominent and has two arteries and one vein liver takes up more space; lower edge .5-2.5 cm below right costal margin bladder is higher; between symphysis and umbilicus abd wall less muscular ; organs easier to palpate

preganancy abd considerations

umbilicus everted and pushed upward nausea and vomitting/ morning sickness - cause unknown but may be due to hormone changes and conduction of chononic gonadotropin (HCG) heartburn/pyrosis caused by esophageal reflux/ acid indigestion decrease in GI motility, (increased gastric emptying time) causes constipation increase in venous pressure and constipation causes hemorroids intestines displaced upward and posterior bc enlarged uterys diminished bowel sound sounds skin changes = stria and linea nigra

auscultating bowel sounds

use diaphragm bc BS highpitched, hold lightly over abd to avoid stimulation begin in RLQ at ileoceccal valve area where BS are almost always present note character and frequency generally sounds are high pitch, gurgling, cascading sounds 5-30/ min or 1 every 5-15 seconds absent sounds are uncommon but very serious; MUST listen for a full 5 minutes before determining is BS are truly present or absent judge if sounds are absent, normal, hypoactive or hyperactive

inspect perianal area

• Spread the buttocks apart • Have client hold their breath and bear down (Valsalva maneuver) • Describe abnormalities in terms of a clock -look for signs of physical abuse (fissures) most should be hairless, folded skin with no lesions fissure = linear split hemorrhoid = flabby skin sac fistula = small round openeing