GI and Abdominal Assessment

Paralytic ileus

complete absence of peristaltic movement that may follow abdominal surgery or complete bowel obstruction

Pyloric stenosis

congenital narrowing of pyloric sphincter, forming outflow obstruction of stomach

Cholecystitis

inflammation of the gallbladder

Peritonitis

inflammation of the peritoneum

Diastasis recti

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

Linea alba

midline tendinous seam joining the abdominal muscles

Cecum

first or proximal part of large intestine

Tympany

high-pitched, musical, drumlike percussion note heard when percussing over the stomach and intestine

Periotoneal friction rub

rough grating sound heard through the stethoscope over the site of peritoneal inflammation

Define the condition benign prostatic hypertrophy, list the usual, symptoms, the man experiences with this condition, and describe the physical characteristics

(BPH) is a histologic diagnosis characterized by proliferation of the cellular elements of the prostate Symptoms: Urinary frequency, urgency, hesitancy, straining to urination, weak stream, intermittent stream, sensation of incomplete emptying, nocturia.

Pyrosis

(heartburn) burning sensation in upper abdomen due to reflux of gastric acid

Striae

(linea albicantes) silvery white or pink scar tissue formed by stretching of abdominal skin as with pregnancy or obesity

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)

Discuss ways of creating an environment that will provide psychological comfort for both the woman and practitioner during the female genitalia examination.

- Have her empty the bladder before examination - Position table so that her perineum is not exposed to a door - Ask if she would like a friend or family member; position this person by woman's head to maintain privacy - Elevate head and shoulders to a semisiting position to maintain eye contact - Place stirrups so that legs are not abducted too far - Explain each step - Assure she can stop the examination at any time - Use gentle, firm touch, and gradual movements - Communicate throughout examination

Tests for Appendicitis

- Iliopsoas Muscle Test: * With person supine, examiner lifts right leg straight up, flexing at hip * Then push down over thigh as patient tries to resist and hold leg up - Obturator Test: * With patient supine, lift right leg, flexing at hip and 90 at knee * Hold ankle + rotate leg internally + externally

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 shifting dulness and its significance

- Percuss down side of abdomen until note change from tympany to dull. Mark this spot. - Roll person towards you - Percuss upper side of abdomen and move downward - Sound changes from tympany to dull and it's highter upward toward the umbilicus Positive result = presence of fluid

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 fluid wave test and its significance

- Place patient's ulnar edge of hand firmly on midline of own abdomen - Place your left hand on person's right flank - With right hand , reach across abdomen and give left flank a firm strike - If a distinct tap is felt on left hand then it is a positive fluid wave test for ascites

What can cause abdominal distention?

-Obesity, air/gas -Ascites -Ovarian cyst -pregnancy -feces -tumor

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

Describe palpation of the kidney

...

Distinguish abdominal wall masses from intra-abdominal masses

...

What three exam techniques can help diagnose appendicitis?

1) Blumberg's sign (rebound tenderness) 2) Iliopsoas muscle test 3) Obturator test

Infants double their weight in the first ____ months and triple their weight by the ____ year.

4 months First year

When assessing a patient for ascites, a positive finding of shifting dullness would be:

A more medial finding of tympany to dullness when the client rolls to the side previous percussed

Discuss ways of creating an environment that will provide psychological comfort for the man and the examiner during examination of the male genitalia

Appropriate draping protects the modesty of the patient. Take time to consider these feelings, as well as to explore your own. Demeanour should be confident and relaxed, unhurried yet businesslike. Do not discuss genitourinary history or sexual practices while you are performing the examination. Use a firm deliberate touch, not s soft, stroking one.

What is the significance of black stools? Contrast this with the significance of red blood in stools

Black, tarry stools= occult blood (melena) from bleeding higher in the GI tract. [blood has been broken down digestive process] Black, nontarry stools= ingesting iron supplements Red blood in stools= localized bleeding in lower GI tract and around the anus (ex: hemorrhoids)

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

Which of the following may be noted through inspection of the abdomen? a. fluid waves and abdominal contour b. umbilical eversion and Murphy's sign c. venous pattern, peristaltic waves, and abdominal contour d. peritoneal irritation, general tympany, and peristaltic waves

C. Venous pattern, peristaltic waves, and abdominal contour

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

Larger purple-blue striae that run up and down abdomen are a sign of _______.

Cushing's Syndrome

If you see pulsations just left of midline, you know you are seeing the _____.

aorta

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

Costovertebral angle (CVA)

angle formed by the 12th rib and the vertebral column on the posterior thorax, overlaying the kidney

Viscera

Internal Organs

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.

The largest organ in the body is the _____.

Liver

Name the organs that are normally palpable in the abdomen

Liver, Spleen, Kidneys, (Aorta)

For each of the following organs state their function: - Liver - Gallbladder - Pancreas - Spleen

Liver: storage (glucose, minerals), protection, metabolism Gallbladder: collects, concentrates, and stores bile from the liver; releases bile into the duodenum Pancreas: exocrine (enzymes to breakdown food) and endocrine (insulin and glucagon) Spleen: stores some RBCs and activates T-lymphocytes

Where are the kidney's located and which kidney is possible to palpate?

Located: Retoperitoneal Palpable: The RIGHT kidney

Costal Margin

Lower border of rib margin formed by the medial edges of the 8th, 9th, and 10th ribs

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.

Inspiratory Arrest (Murphy Sign)

Pain as a result of holding fingers under the liver border and pt taking a deep breath. Pain= inflammation of gallbladder

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

State the method of promoting anal sphincter relaxation in order to aid palpation of the anus and rectum.

Place the pad of your index finger gently against the anal verge. You will feel the sphincter tighter, and then relax. As it relaxes, flex the tip of your finger and slowly insert it into the anal canal in a direction toward the umbilicus.

The _____ kidney tends to be 1-2 cm lower than the ___ kidney and ____ be palpable.

RIGHT kidney is 1-2cm lower than the LEFT kidney and MAY be palpable

List a few examples of high-fibre foods of the soluble type and of the insoluble type; what advantages do these foods have for the body?

Soluble type (beans, prunes, barley, carrots, broccoli, cabbage) have been shown to lower cholesterol, while insoluble-fibre foods (cereals, wheat germ) reduce the risk of colon cancer. Also fibre foods fight obesity, stabilize blood sugar and help certain gastrointestinal disorders.

List teaching points to include with the teaching of testicular self-examination

T = timing, once a month... S = shower, warm water relaxes scrotal sac... E = examine, check for changes, report changes immediately

Describe the significance of the inguinal canal and the femoral canal.

They are potential sites for a hernia, which is a loop of bowel protruding through a weak spot in the musculature.

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.

An irreducible hernia should be referred for surgical consultation because these hernias are at risk of: a. Strangulation b. Pulsations c. Regurgitation d. Constipation

a. Strangulation

Mild discomfort is normal when palpating the sigmoid colon. a. True b. False

a. True

It is normal to see aortic pulsations just left of the midline especially on a thinner person. a. true b. false

a. True (may also be able to see respirations)

Auscultation of the abdomen may reveal bruits of the ______ arteries. a. aortic, renal, iliac, and femoral b. juglar, aortic, carotid, and femoral c. pulmonic, aortic, and portal d. renal, iliac, internal jugular, and basilic

a. aortic, renal, iliac and femoral

Shifting dullness is a test for: a. ascites b. splenic enlargement c. inflammation of the kidney d. hepatomegaly

a. ascites

Auscultation of the abdomen is begun in the right lower quadrant (RLQ) because: a. bowel sounds are always normally present here b. peristalsis through the descending colon is usually active c. this is the location of the pyloric sphincter d. vascular sounds are best heard in this area

a. bowel sounds are always normally present here

The nurse is percussing the 7th right ICS at the MCL over the liver. Which should should the nurse expect to hear? a. dullness b. tympany c. resonance d. hyperresonance

a. dullness

Right Upper Quadrant tenderness may indicate pathology in the: a. liver, pancreas, or ascending colon b. liver and stomach c. sigmoid colon, spleen, or rectum d. appendix or ileocecal valve

a. liver, pancreas, or ascending colon

The linea alba separates the: a. right and left quadrants b. upper and lower quadrants

a. right and left quadrants

Ascites

abnormal accumulation of serous fluid within the peritoneal cavity, associate with congestive heart failure, cirrhosis, cancer, or portal hypertension

Hepatomegaly

abnormal englargment of liver

Splenomegaly

abnormal enlargement of spleen

Hernia

abnormal protrusion of bowel through weakening in abdominal musculature

Scaphoid

abnormally sunken abdominal walls as with malnutrition or underweight

Your patient states that he has been having epigastic achiness that is alleviated with eating. You know that these are signs of: a. Blockage of the common bile duct b. Duodenal ulcers c. Gastric ulcers d. Heart burn

b. Duodenal ulcers

The nurse is listening to bowel sounds. Which of these statements is true of bowel sounds? a. they are usually loud, high pitched, rushing, tinkling sounds b. they are usually high-pitched, gurgling, irregular sounds c. they sound like two pieces of leather being rubbed together d. they originate from the movement of air and fluid through the large intestine

b. They are usually high-pitched, gurgling, irregular sounds

During an abdominal assessment, the nurse would consider which of these findings as normal? a. the presence of a bruit in the femoral area b. a tympanic percussion note in the umbilical region c. a palpable spleen between the 9th and 11th ribs in the left MAL d. a dull percussion note in the LUQ at the MCL

b. a tympanic percussion note in the umbilical region

Murphy sign is best described as: a. the pain felt when the hand of the examiner is rapidly removed from an inflamed appendix b. pain felt when taking a deep breath when the examiner's fingers are on the approximate location of the inflamed gallbladder c. a sharp pain felt by the patient when one hand of the examiner is used to thump the other at the costovertebral angle. d. not a valid examination technique

b. pain felt when taking a deep breath when the examiner's fingers are on the approximate location of the inflamed gallbladder

The spleen ______ be palpable. a. should b. shouldn't

b. shouldn't

Bruit

blowing, swooshing sound heard through a stethoscope when an artery is partially occluded

The absence of bowel sounds is established after listening for: a. 1 full minute b. 3 full minutes c. 5 full minutes d. none of the above

c. 5 full minutes

Cullen's sign is: a. A normal finding b. A bluing around the umbilicus caused by irreducible hernia c. A bluing around the umbilicus caused by retroperitoneal bleeding d. An abnormal finding caused by iliac artery stenosis

c. A bluing around the umbilicus caused by retorperitoneal bleeding.

While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are: a. pulsations of the renal arteries b. pulsations of the inferior vena cava c. normal abdominal aortic pulsations d. increased peristalsis from a bowel obstruction

c. normal abdominal aortic pulsations

Tenderness during abdominal palpation is expected when palpating: a. the liver edge b. the spleen c. the sigmoid colon d. the kidneys

c. the sigmoid colon

The range of normal liver span in the Right MCL in the adult is: a. 2-6 cm b. 4-8 cm c. 8-14 cm d. 6-12 cm

d. 6-12 cm

Hyperactive bowel sounds are: a. high pitched b. rushing c. tinkling d. all of the above

d. all of the above (high pitched, rushing, tinkling)

The nurse is aware that one change that may occur in the GI system of an aging adult is: a. increased salivation b. increased liver size c. increased esophageal emptying d. decreased gastric acid secretion

d. decreased gastric acid secretion

A dull percussion note forward of the left midaxillary line is: a. normal, an expected finding during during splenic percussion b. expected between the 8th and 12th ribs c. found if the examination follows a large meal d. indicative of splenic enlargement

d. indicative of splenic enlargement

The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition? a. Percuss and palpate in the lumbar region b. Inspect and palpate in the epigastric region c. Auscultate and percuss in the inguinal region d. Percuss and palpate the midline area above the suprapubic bone

d. percuss and palpate the midline area above the suprapubic bone

A positive Blumberg sign indicates: a. a possible aortic aneurysm b. the presence of renal artery stenosis c. an enlarge, nodular liver d. peritoneal inflammation

d. peritoneal inflammation

Striae, which occur when the elastic fibers in the reticular layer of the skin are broken after rapid or prolonged stretching, have a distinct color when of long duration. This color is: a. pink b. blue c. purple-blue d. silvery white

d. silvery white

The left upper quadrant (LUQ) contains the: a. liver b. appendix c. left ovary d. spleen

d. spleen

Aneurysm

defect or sac formed by dilation in artery wall due to atherosclerosis, trauma, or congenital defect

Umbilicus

depression on the abdomen marking site of entry of umbilical cord

Dysphagia

difficulty swallowing

Inguinal Ligament

ligament extending from pubic bone to anterior superior iliac spine, forming lower border of abdomen

Anorexia

loss of appetite for food

Borborygmi

loud, gurgling bowel sounds signaling increased motility or hyperperistalisis, occurs with early bowel obstruction, gasteroenteritis, diarrhea

Rectus abdominis muscles

midline abdominal muscles extending from rib cage to pubic bone

Epigastrium

name of abdominal region between the costal margins

Suprapubic

name of abdominal region just superior to pubic bone

You are palpating for the liver border and the client suddenly cries out in pain. You document this as a _____ Murphy's sign and examine the client for other signs of ______.

positive murphy's sign. signs of cholecystitis

During the abdominal assessment, you percuss anteriorly to the left midaxillary and hear dullness. What does this indicate? a. splenomegaly b. hepatomegaly c. normal finding d. ascites

splenomegaly