Abdominal and Musculoskeletal Assessment

Inspiratory Arrest or Murphy sign

when palpating the liver, there is pain and when client is asked to take a deep breath, they stop breathing when there is gallbladder (cholecystitis).

goniometer

A goniometer is used to measure the angles of joint flexion accurately. Page 615, Fig. 21.11

Bulge

little fluid in knee

Phalen test

- ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. The Phalen's test reproduces numbness and burning in a person with carpal tunnel syndrome.

kidneys

2 containing more than 1 million nephrons each. Nephrons composed of a tuft of capillaries, the glomerulus, a proximal convoluted tubule, the loop of Henle, and a distal convoluted tubule. The distal tubule empties into a collecting tubule. Glomeruli filter the blood of: electrolytes, glucose, water, & small proteins. Both an excretory organ & an endocrine gland. Excretory organ - responsible for the removal of water-soluble waste. Endocrine gland - produces renin, which controls aldosterone secretion. Aldosterone acts in the renal tubule to retain sodium, conserve water, and increase potassium excretion in the blood.

Ureters and Bladder

2 ureters connecting the kidneys to the bladder. Peristaltic waves move the urine from the kidneys to the bladder. Bladder Serves as a urinary reservoir Capacity of approx. 400 - 500 ml in the adult

Percuss the abdomen

4 quadrants Gastric air bubble Liver span- p. 577 (6-12 cm; 10.5 males, 7 for females); enlarged liver span- hepatomegaly Splenic dullness CVA tenderness General tympany- clear, hollow drumlike beating over hollow organs- empty stomach or bowel Dullness- muffled sound over solid organs such as liver, kidney, feces filled intestines Gastric bubble - percuss abdomen in area between left costal margin and midsternal line below xiphod process; sound is tympany; influenced by stomach contents. Dull is a mass or after a meal. Very loud sound is gastric dilation. Liver span Usual technique Scratch test Note with chronic emphysema, liver is displaced because of hyperinflated lungs, so liver span is not accurate. Splenic dullness- can be displaced by full stomach, but normally splenic dullness not more than 7 cm and should not encroach on normal tympany of stomach- over gastric air bubble. Dull note 9th to 11th rib left midaxillary line. Enlarged note means infection, mono, or trauma to spleen. Enlarged spllen- hear dullness in left anterior axillary line at 11th ICS. Costovertebral angletenderness- indicative of kidney infection- pyleonephritis Special procedures Fluid wave Shifting dullness Auscultation of the abdomen is an important nursing assessment, especially for postoperative patients. Although the clicks of a normal bowel can occur anywhere from 5 to 30 times per minute, the nurse must listen for up to 5 minutes before deciding that bowel sounds are completely absent. In addition to bowel sounds, the examiner must note whether any vascular sounds or bruits are present. Percussion reveals the relative density of the abdominal contents. Because of air in the intestines, tympany is the predominant sound. Dullness may be heard over a distended bladder, adipose tissue, fluid, or a mass. A change in tone may be noted over the descending colon if there is a need for evacuation. A change from lung resonance to dullness will identify the borders of the liver, which ranges from 6 to 12 cm in width and, on some individuals, splenic dullness, which is 7 cm in width or less, may be noted between the ninth to eleventh intercostal space behind the left midaxillary line.

Muscle Strength Grading-

5 Full ROM against gravity, full resistance 4 Full ROM against gravity, some resistance 3 Full ROM against gravity 2 Full ROM with gravity eliminated (P-ROM) 1 Slight contraction 0 No contraction

PUD

A bleeding ulcer. can end up to intermitten right upper quadrant pain 2 to 3 hours after eating

Abdominal Vasculature

Abdominal Aorta (descending aorta) Branches off into 2 common iliac arteries, and the splenic & renal arteries Supplies oxygenated blood to parts of the body Inferior Vena Cava Receives blood from the 2 common iliacs, the lumbar veins & the testicular veins. Returns deoxygenated blood to the heart from parts of the body. Superior Mesenteric Artery & Vein Supplies & draws blood from most of the small intestine, the cecum, and the ascending & transverse colons.

Common Symptoms

Abdominal symptoms- terms on pages 953-54 Indigestion; anorexia Nausea, vomiting, hematemesis; abdominal pain Dysphagia, odynophagia Change in bowel function Constipation; diarrhea Jaundice/icterus Urinary/renal symptoms Incontinence; kidney/flank pain; ureteral colic

Lifespan Considerations: Older Adult: abdomen

Additional questions Risks for nutritional deficit Bowel function Daily medications Potential alterations Poor dentition- reabsorption of bone; reduced absorption of Vit. D and decline in enamel Decreased muscle mass, tone Decreased motility, peristalsis bloating, distention, constipation Liver shrinkage decreased medication metabolism Decreased renal function decreased medication efficacy and ability to eliminate Cultural considerations- See page 571 African; Asian; Jewish; Mediterranean Native Americans With aging, decreased production of saliva and stomach acid Gastric motility and peristalsis slow. Diminished thirst mechanism Alcohol and drug abuse more common in Native Americans and African Americans Obesity more frequent in Hispanic and African Americans Japanese greater risk for gastric cancer Lactose intolerance greater in non-white and Jewish Americans Consider culture- may need same sex examiner because of disrobing issues

Explain how to assess the liver? What is the scratch test? What is normal finding and abnormal finding?

After placing a stethoscope over the approximate location of a patient's liver, a medical professional will then scratch the skin of the patient's abdomen lightly, moving laterally along the liver border. When the liver is encountered, the scratching sound heard in the stethoscope will increase significantly. In this manner, the size and shape of a patient's liver can be ascertained. Measures to promote liver health are discussed. Many behaviors can increase the risk of hepatitis. The three leading causes of hepatitis are hepatitis A, hepatitis B, and hepatitis C infections. Vaccinations are available for both hepatitis A and hepatitis B.

Lifespan Considerations: Older Adults : muscle

Aging effects Loss of bone density (osteoporosis) Men < women Risk factors Race; heredity; hormonal factors; physical activity; calcium intake; smoking; high salt intake; alcohol intake Postural changes; decreased height Decreased joint flexibility Lifespan considerations: older adults Extra time for assessments Gait speed assessment Cultural considerations Older Adult Bone resorption happens more rapidly than new bone growth leads to loss of bone density, osteoporosis Vertebral column shortens so decreases in height Shift in center of gravity increases risk for falls Size and quantity of muscle fibers decrease; connective tissue increases making muscles fibrous, stringy Tendons less elastic; decrease in agility, reaction time, movement speed, endurance Kyphosis Joints degenerate; less ROM and flexibility; osteoarthritis Asians and Caucasians have greater risk for osteoporosis African Americans have greater bone density Curvature of bones vary among various cultural groups related to body weight and genetics Thin person has less curvature of spine and obese have more

Small Intestine

Approx. 21 feet long: Duodenum, jejunum, ileum Begins at plyoric orifice and ends at ileocecal valve Digestion completed through action of pancreatic enzymes, bile, several small intestine enzymes Nutrients absorbed through walls

Large Intestine

Approx. 4.5- 5 feet long and 2.5 inches in diameter: Cecum Ascending Colon Transverse Colon Descending Colon Sigmoid Colon Absorption of water takes place Lubrication of contents by secreted mucus. Neutralization of acids by an alkaline mucous secreted. Live bacteria decompose undigested food, unabsorbed amino acids, cell debris, and dead bacteria.

Assessment- screening vs. full assessment

Assesses for ability to deal with ADLs. History questions can gain info. Screening for most- how walks, takes off jacket, rises from chair, ROM, inspect/palpate joints in each region as at that area. Complete for articular disease, , musculoskeletal problems or difficulty performing ADLs. Muscle testing Grades 0-5, Table 21.6 p. 618

subjective data: abdomen

Assessment of risk factors Personal history General GI questions; chewing and swallowing Breathing; weight gain; GU issues; joint pain Neurological system; metabolism; skin Lymphatic, hematological systems Substance abuse; occupation; foreign travel Lifestyle Medications Family history dysphagia?

Subjective Data : musceoskeletal

Assessment of risk factors Personal history Occupation, lifestyle, behaviors Medications Family history Psychosocial history

What findings constitute an enlarged bladder?

Can palpate above symphysis pubis- has enlarged bladder; hear dull sounds- retained urine. Use fingers of one hand to palpate lower abd. In light dipping motion; distended bladder is firm, smooth and extends above symphysis pubis.

If abdominal pain is really bad

skip assessment and send patient to the doctor

Bulge sign-

small amount of fluid in knee joint, can displace fluid, see page 620

Know these tests

Ballottment- to test for large amounts of fluid around the patella. see page 620 Bulge sign- small amount of fluid in knee joint, can displace fluid, see page 620 Phalen- ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand. The Phalen's test reproduces numbness and burning in a person with carpal tunnel syndrome. Tinel's sign-p. 619 McMurray's test- tests for meniscal tears; while taking knee through motion with inward stress on knee with rotation, hear or feel a click- positive for tear. See p. 621

Auscultate the abdomen

Bowel sounds normoactive, hyperactive, hypoactive, absent Vascular sounds Bowel sounds- diaphragm in RLQ (ileocecal valve area) slightly below and to right of umbilicus; auscultate clockwise in each of 4 quadrants; note character, quality of sounds in each quad. Clamp off NG tube to wall suction when listening bc sx noises can obscure or mimic bowel sounds Vascular sounds (bruits)- listen with bell and firmer pressure over aorta, renal, iliac, femoral arteries

What conditions lead to hypoactive bowel sounds? Hyperactive? Absent? Describe bowel sounds and how frequent and how long should a nurse listen before deciding that the bowel sounds are absent?

Bowel sounds are high-pitched, gurgling, cascading sounds that occur irregularly from 5 to 30 times per minute. They originate from the movement of air and fluid through the small intestine. Hypoactive bowel sounds signal decreased motility with peritonitis, paralytic ileus, after abdominal surgery or bowel obstruction. Also can happen with pneumonia. (heard infrequently) Hyperactive bowel sounds is from increased motility or with early mechanical bowel obstruction, diarrhea, laxative use, gastroenteretitis, or paralytic ileus that subsides. (Loud, high-pitched, tinkling sounds occur frequently) Must listen for 5 minutes before can determine bowel sounds are completely absent.

Critical Thinking: abdomen

Common laboratory and diagnostic testing Labs: CBC; BMP Esophagogastroduodenoscopy (EGD) Barium enema Colonoscopy Endoscopic retrograde cholangiopancreatography (ERCP) Computed tomography scan (CT) Magnetic resonance imaging (MRI) Diagnostic reasoning: nursing diagnoses, outcomes, interventions Outcomes (partial list) Patient will defecate formed stool every 1 to 3 days. Patient will report decrease in incontinent episodes. Interventions (partial list) Teach patient to pace fluids, limit bedtime intake. Administer bulk laxatives per physician order.

stomach

Consists of 3 lobes: Fundus Body Pylorus Breakdown of food particles Very little absorption takes place in the stomach. Secretes hydrochloric acid and digestive enzymes to breakdown fats and proteins.

Nursing Diagnosis

Constipation Diarrhea Urinary retention Incontinence, bowel or urinary Imbalanced nutrition Pain

Risk Reduction and Health Promotion

Health goals Bone density Comprehensive osteoporosis strategy Calcium, vitamin D intake Limit caffeine increased calcium secretion Weight-bearing exercise Avoid smoking, alcohol Bone density test, medication as prescribed Scoliosis screening

Abnormal skin color changes

Cullen's sign- bluish umbilicus; indicates intra-abd. Hemorrhage Turner's sign- bruise on flank; indicates retroperitoneal hemorrhage Other Abnormal Findings: Dilated, tortuous, visible abd. Veins- may indicate inferior vena cava obstruction Prominent, dilated veins may mean portal hypertension with liver dysfunction; also see ascites, and tight, shiny skin Abd. Redness- may indicate inflammation

Explain how to assess the kidneys and what is normal vs. abnormal? Explain assessment of renal arteries? What does a bruit mean? Page 582 for kidney assessment.

Renal arteries- see page 575, Fig. 20.7. A bruit in the renal artery signals the possibility for renal artery stenosis, which warrants further investigation by the primary health provider.

Urgent Assessment : muscle

Foci Identifying specific problem Alleviating pain Preventing complications GALS locomotor screen- p. 607 Gait Arms Legs Spine

Understand how to use the rating muscle strength scale and using critical thinking- what patient populations would you expect to see the following ratings? Critical thinking question answers may vary.

Grade 5- client with normal function Grade 4- client with muscle weakness from prolonged bedrest or sports injury, etc. Grade 3- client after a stroke beginning recovery or client after prolonged bed rest, sports injury Grade 2- client after stroke Grade 1- client after stroke Grade 0- client after stroke with flaccidity

Risk Reduction and Health Promotion: abdomen

Health promotion and goals Colorectal cancer screening Reduce new cases of end stage renal disease (ESRD) Reduce cirrhosis deaths Risk reduction Colorectal cancer; food-borne illness Hepatitis: A, B, C Hepatitis A, B immunizations Screening, patient teaching 50 or older need colorectal screening Diet rich in antioxidants, low in fats, and high in fiber, avoid red meat and processed meats, such as cold cuts, hot dogs, etc. Screen for alcohol consumption using CAGE and avoid excessive consumption of alcohol.

Liver

Heaviest organ in the body (approx. 3 lbs.)- 4 lobes with lobules Metabolism of carbohydrates, fats, and proteins Glucose conversion, storage & release Amino acids are converted into glucose Bile salt formation from cholesterol Storage of several minerals & iron Detoxification & release of harmful substances -"excretory organ" Production of antibodies Synthesis of fats from carbohydrates & proteins Proteins are broken down to amino acids Excretion of steroid hormones Production of prothrombin, fibrinogen and other substances for blood coagulation Production of proteins that circulate in the blood converts fat-soluble waste into water soluble waste for renal excretion

Explain borbory gmi?

Hyperactive bowel sounds because of hyperperistalis when the person can feel his stomach growling.

What measures are needed to help a client relax before an abdominal exam?

If the abdomen is to be assessed accurately, patient relaxation is essential. The bladder must be empty, the room a comfortable temperature, the patient comfortable with knees supported, arms at the sides, and good lighting and visualization of the entire abdomen available. Make sure the stethoscope endpiece is warm and that your fingernails are short. Examine painful areas last to avoid muscle guarding. To promote relaxation- empty bladder, keep room warm, position supine with pillow under head, knees bent or on a pillow, arms at side or across chest, warm stethoscope and keep nails short. Find out where painful areas are and examine that area last to avoid muscle guarding. Use distraction to promote relaxation- soothing voice, ask about history regarding abdomen during exam, or breathing exercises

Nursing Diagnosis : musceoskeletal

Impaired physical mobility Pain Risk for Trauma Risk for Disuse Activity intolerance Disturbed body image

Abdominal aortic anurism

Increased Abd. aortic s

Temporomandibular joint

Inspect joint area Palpate as person opens mouth Motion and expected range Open mouth maximally Protrude lower jaw and move side to side Stick out lower jaw Palpate muscles of mastication Crepitus and pain occur with temporomandibular joint dysfunction

Objective Assessment: abdomen

Inspect- at rest, then after taking a deep breath Contour Symmetry Umbilicus should be midline and inverted; (hernias)- protrusion of abd. Viscera through abd. Opening in muscle wall. Scars, striae, moles, masses, nodules Movement, pulsation- thin muscular persons can see aorta pulsations in epigastric area; see waves of peristalsis, and often respiratory movement, esp. males Marked visible peristalsis and distended abd. = intestinal obstruction Hair distribution - diamond shape in males and inverted triangle in females Inspect the abdomen Contour Symmetry Umbilicus- should be inverted and located midline in abd.; may protude with pregnancy, ascites, underlying mass, (umbilical hernia- assess with pt. raising head and shoulders) Skin- smooth, uniform in color; new striae are pink or blue and old are silvery white; dark skin will be dark brown; note dilated veins; record length of surgical scars Pulsation or movement- visible rippling waves may indicate bowel obstruction and need reported immediately; aorta visible for pulsations in thin person in the epigastric area; marked pulsations occur with htn, aortic insufficiency, aortic aneurysm and disorders causing a widened pulse pressure Hair distribution Demeanor Contour, symmetry, shape of the umbilicus, condition of the skin on the abdomen, and presence of pulsations or movement all must be observed during inspection of the abdomen. The examiner must discriminate between normal and abnormal findings and use the information obtained through inspection as a basis for further exploration if indicated. The pattern of pubic hair growth and demeanor of the patient should be assessed with inspection.

Objective Assessment musculoskeletal

Inspection Size, shape, color, & symmetry Swelling, masses, deformity, or atrophy Palpation Temperature Tenderness Pain Nodules Crepitus Edema Test ROM Joints TMJ Open mouth Lateral Protrude & retract Sternoclavicular & Acromioclavicular Inspect & palpate Spine - cervical, thoracic, & lumbar Curvature Flexion & extension Lateral bend Shoulders- Figure 21.16, p. 626 Flexion & extension Adduction & abduction External rotation & internal rotation Elbows- Figure 21.8, p. 628 Flexion & extension Pronation & supination Wrists- p. 629 Flexion & extension Deviation Hands & Fingers- See page 629 Flexion & extension Abduction & adduction Thumb movement Grip strength Extra tests- See page 619 Phalen's Tinel's Hips- See Figure 21.22, p. 630 Flexion (knee straight & bent) & extension Abduction & adduction Inward rotation & external rotation Knees- See Figure 21.23, p. 631 Flexion & extension Extra tests Bulge test Ballottement test McMurray's test Ankles & Feet- See Figure 21.25, p. 634 Dorsiflexion & plantar flexion Eversion & inversion Flexion & extension of toes Extra Tests LaSegue's- p. 622 Leg Length- p. 617 Fall risk Morse Fall Scale (MFS) Box 21.1 page 637

Abdominal and Musculoskeletal Assessment objectives

Learning Objective 1. Demonstrate knowledge of anatomy and physiology of the GI/GU and vascular system of the abdomen. Learning Objective 2. Identify aspects to ask during the health history to evaluate the abdomen. Learning Objective 3. Identify aspects to assess during the physical of the abdomen. Learning Objective 4. Explain how to correctly assess the abdomen of the patient. Learning Objective 5. Differentiate normal and abnormal findings from the assessment of the abdomen and the significance of abnormal findings. Learning Objective 6. Identify health promotion aspects to include during the history and physical of the abdominal assessment. Learning Objective 7. Document subjective and objective findings using proper medical terminology of the abdominal assessment. Learning Objective 8. Identify aging considerations for the abdominal assessment. Learning Objective 9. Identify cultural considerations from the text and PP for the abdominal assessment. Learning Objective 10. Properly identify nursing diagnoses for data obtained from the history and physical of the abdominal assessment. Learning Objective 11. Prioritize health problems of the client with abdominal disorders. Learning Objective 12. Practice communicating problems of the abdomen using SBAR. Musculoskeletal Assessment Learning Objective 1. Demonstrate knowledge of anatomy and physiology of the musculoskeletal systems. Learning Objective 2. Identify aspects to ask during the health history to evaluate the musculoskeletal system. Learning Objective 3. Identify aspects to assess during the physical of the musculoskeletal system. Learning Objective 4. Explain how to correctly assess the musculoskeletal system of the patient. Learning Objective 5. Differentiate normal and abnormal findings from the assessment of the muscles and skeletal systems and the significance of abnormal findings. Learning Objective 6. Identify health promotion aspects to include during the history and physical of the musculoskeletal assessment. Learning Objective 7. Document subjective and objective findings using proper medical terminology of the musculoskeletal assessment. Learning Objective 8. Identify aging considerations for the musculoskeletal assessment. Learning Objective 9. Identify cultural considerations from the text and PP for the musculoskeletal assessment. Learning Objective 10. Properly identify nursing diagnoses for data obtained from the history and physical of the musculoskeletal assessment. Learning Objective 11. Prioritize health problems of the client with muscle or skeletal disorders. Learning Objective 12. Practice communicating problems of musculoskeletal assessment using SBAR.

Pancreas

Lies behind & beneath the stomach Exocrine & an endocrine gland Exocrine gland: Digestive juices are produced by the acinar cells of the pancreas. The juices contain inactive enzymes for the breakdown of proteins, fats, and carbohydrates. Endocrine gland: Islet cells within the pancreas produce both insulin & glucagon. These are secreted directly into the blood to regulate the body's level of glucose

Why is light palpation used and how does the nurse perform it- how far and with what? Why is deep palpation used and how does the nurse perform it?

Light and deep palpation provides the examiner with the ability to distinguish normal organs, enlarged organs, abnormal masses, and unusual sensations elicited. Light palpation-1 first 4 fingers depress 1 cm with gentle rotary motion. Move clockwise over entire abd. Deep palpation- same as above but push down 5-8 cm or 2-3 inches. Bimanual palpation- for obese- 2 hands on top of each other. Bottom one senses and top gives extra push needed. Light and deep palpation provides the examiner with the ability to distinguish normal organs, enlarged organs, abnormal masses, and unusual sensations elicited. Light palpation-1 first 4 fingers depress 1 cm with gentle rotary motion. Move clockwise over entire abd. Deep palpation- same as above but push down 5-8 cm or 2-3 inches. Used to note the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses. Bimanual palpation- for obese- 2 hands on top of each other. Bottom one senses and top gives extra push needed.

Explain how to assess the spleen? What is an abnormal vs. normal finding?

Page 579 - percuss from left mcl along the costal margin to left midauxillary line, if you hear tympany, spleanomegaly is unlikely. take deep breath and hold it. percuss again. abnormal is when tympany turns to dullness on inspiration.

Explain how to assess the abdominal aorta and what is normal vs. abnormal findings? What should be expected with the femoral artery if the aorta is enlarged?

Page 583- normal aorta is 2-3 (some books say 4)cm wide If aorta is enlarged, may hear a bruit at the femoral artery.

Common Symptoms musculoskeletal

Pain or discomfort Weakness Stiffness or limited movement Deformity Lack of balance and coordination

visceral pain

Pain that occurs when hollow organs are distended, stretched, or contract forcefully.

Iliopsoas Muscle Test

Perform when thinking appendicitis. Client is supine, lift right leg straight up flexed at hip and then push down on lower part of right thigh as client tries to keep leg up. Positive test, the iliopsoas muscle is inflamed and pain is felt in right lower quadrant with inflamed or perforated appendix.

Tineal test

Positive is when you Palpate lightly over median nerve of the wrist and it will cause pain

urgent assessment : abdomen

Potentially life-threatening symptoms that require prompt attention Severe dehydration: nausea, vomiting Fever Acute abdominal pain

Name the location of organs and structures within the abdomen by quadrant.

RUQ- right lobe of liver, gallbladder, pylorus, duodenum, head of pancreas, hepatic flexure of colon, portions of ascending and transverse colon LUQ- left lobe of liver, stomach, body of pancreas, splenic flexure of colon, portions of transverse and descending colon RLQ- cecum and appendix, portion of ascending colon LLQ- sigmoid colon, portion of descending colon

acute pancreatitis

S/s: Severe epigastric pain radiates to the back/ or flanks. Cullen sign- superficial oedema and bruising in the subcutaneous fatty tissue around the umbilicus, Grey Turner sign- bruising of the flanks, the part of the body between the last rib and the top of the hip., Paralytic ileus. Amlase and lipase levels are elevated Predominantly males: because they smoke and drink Females: Because of gallbladder disease

Documentation: Abdomen

S: No hx. Abd. Disease or surgery. Denies recent bowel changes, has 1 formed BM/day. Denies abd pain, N & V. O: Abd flat, symmetric with no apparent masses upon inspection. Skin smooth with no striae, scars or lesions. Bowel sounds normoactive, no hums or bruits. Tympany noted upon percussion in all 4 quadrants. Soft, no tenderness, guarding, or masses upon light palpation.

Documentation Muscleoskeletal

S: States no hx. of muscle, bone, or joint disease. No hx. of trauma or deformities. No joint pain, stiffness, swelling, or limitation. No muscle pain or weakness. Able to manage all usual daily activities with no physical limitations. Occupation involves no musculoskeletal risk factors. Exercise pattern is brisk walk 1 mile 5x / week. No recent wt. gain. No dairy products in diet. O: Joints and muscles symmetric; no swelling, masses, deformity; normal spinal curvature. No tenderness to palpation of joints; no heat, swelling, or masses. Full ROM; movement smooth, no crepitance, no tenderness. Muscle strength=5 on a 0-5 scale. Hand grip strength equal bilaterally.

gallbladder

Saclike, pear shaped organ about 4 in. Long. Concentrates & stores bile from the liver. Bile is composed of cholesterol, bile salts, & pigments. Acts to maintain the alkaline (basic) pH of the small intestine to permit emulsification (breakdown) of fats so that absorption can be accomplished.

What are the effects of aging on the GI system?

Salivation decreases; alters sense of taste; dry mouth Delayed esophageal emptying; make sure to feed upright Decreased gastric secretions; decreased B12 absorption, increased risk for pernicious anemia; decreased absorption of iron, calcium Decreased liver size- decreased metabolism of drugs Increased incidence of gallstones Decreased GI motility; increased risk for constipation

Spleen

Upper left quadrant Consists of white pulp (lymphoid tissue) & red pulp. White pulp (lymphoid tissue) Constitutes most of the spleen Part of the reticuloendothelial system to filter blood & manufacture lymphocytes & monocytes. Red pulp A capillary network & venous system that allows for the storage and release of blood. Allows the spleen to hold up to several hundred milliliters at 1 time.

Define the 4 contours of the abdomen?

The profile is from the rib margin to the pubic bone and the contour describes the nutritional state. Should be flat to rounded in average weight. Will be slightle concave in slender client. Protuberant- unusual or prominent convexity of abdomen due to excessive subcutaneous fat, poor muscle tone or increased intraabdominal contents. Scaphoid- condition in which anterior abd. Wall is sunken and concave presence instead of a normal flat contour is seen. Flat- normal abdomen, which there is no concavity or convexity of the abd. wall seen. Rounded- convexity of abdomen is seen.

Why is the order of assessment for the abdomen inspection, auscultation, percussion, palpation?

The sequence for examining the abdomen is inspection, auscultation, percussion, and palpation. This is done because percussion and palpation can increase peristalsis and might give a false interpretation of bowel sounds.

Palpation: abdomen

Use of four fingers close together the skin is depressed 1 cm and a gentle rotary motion sliding fingers and skin together is used during light palpation. Nurse moves clockwise and saves tneder area last. Observe for muscle guarding, rigidity, any large masses or tenderness during light palpation. Deep palpation is 3-8 cm with same technique. Bimanual palpation can be used for obese abdomen. The deep palpation is to note location, size, consistency, mobility of any palpable organs and if any enlargements are present or masses or tenderness. Mild tenderness normal over sigmoid colon in left lower quadrant. Measures to promote liver health are discussed. Many behaviors can increase the risk of hepatitis. The three leading causes of hepatitis are hepatitis A, hepatitis B, and hepatitis C infections. Vaccinations are available for both hepatitis A and hepatitis B.

carpal tunnel syndrome

Tineal- way to detect irritated nerves. It is performed by lightly tapping (percussing) over the nerve to elicit a sensation of tingling or "pins and needles" in the distribution of the nerve and phalen test- test CTS b pushing wrists together hands pointing down.

paralytic ileus

absent bowel sounds, Listen for 5 min before can determine truly absent.

true leg length

apparent leg length can be measured from the umbilicus to the medial malleoli of the ankle (Fig. 2). A "direct" measurement using a tape measure can be utilized to measure the "true" leg length from the anterior superior iliac spine (ASIS) to the medial malleolus.

before assessing the abdomen make sure to do these to increase comfort.

ask client to empty bladder, place a pillow under the knees in supine position (will relax abdomen), warm hands and stethoscope, Save tender areas for last, perform assessment: Inspection, ascultation, percussion, palpation

convex

dips down, protruding, protrubrit

concave

dips, sinks in

Measuring abdominal girth

done with measuring tape around patient at level of umbilicus

Apendicitis

fever PAin RLQ

Cirrhoosis of the liver

heptomegaly, increased abdominal girth, fluid wave. Stool clay colored, urine tea colored, increased liver enzymes and increased bilirubin, yellow sclera/ skin > jaundice

Positive murphys sign

in gallbladder , urine is tea colored, stool is clay colored, increased bilirubin, may have jaundice, yellow sclera

lasegue's test

looks for herniation in the lumbar disc.

Bullottment

lots of fluid in the knees

EGD (esophagogasturalduooscopy)

scope down esohpagus to doedenum.

Fluid wave-

suspect ascites because of distended abdomen, bulging flanks, protruding umbilicus that is displaced down. Stand on client's right side and place ulnar edge of another examiner's hand at abd. Midline or client's hand. Tap opposite side and feel with your other hand and see if you feel a wave. Fluid wave is present with large amount of fluid present in conditions such as cirrhosis of the liver, hepatitis, portal hypertension, pancreatitis, and cancer in that area.

McMurray's test-

tests for meniscal tears; while taking knee through motion with inward stress on knee with rotation, hear or feel a click- positive for tear. See p. 624

What is ascites and how does the nurse assess for it?

the accumulation of fluid in the peritoneal cavity, causing abdominal swelling. Have another nurse place ulnar edge of hand firmly on pt. abd. At midline. Stand facing pt. head and place palm of your right hand against left flank. Give right abd. Firm tap with left hand. If it is present, see and feel fluid wave across abd.

Ballottment-

to test for large amounts of fluid around the patella. See p. 620

Rebound Tenderness or Blumberg Sign

used when a client has RLQ pain and may have appendicitis, or peritonitis.