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