Abdominal Assessment vocabulary
The nurse suspects a patient has appendicitis what 2 procedures do you use?
1. Blumberg's sign 2. perform iliopsoas muscle test
What is the correct sequence for auscultation of the abdomen?
1. RLQ 2. RUQ 3. LUQ 4. LLQ if there is pain present, then maintain a systemic approach ex: pain in RUQ 1. RLQ always do first because bowel sounds are normally present here 2. LLQ (compare 2 lower quadrants) 3. LUQ 4. RUQ (done last due to the presence of pain)
What does a DULL sound over the suprapubic area upon percussion indicate?
Bladder distention
Which method would the nurse use to assess a client suspected of having a distended bladder? A. inspect and palpate the epigastric region B. auscultate and percuss the inguinal areas C. percuss and palpate the hypogastric region D. bilaterally percuss and palpate the lumbar regions
C. percuss and palpate the hypogastric region Hypogastric = pubic region percussion of a distended bladder would produce a dull sound and feel firm upon palpation
When preparing to assess the four abdominal quadrants of a client who reports stomach pain, when would the nurse assess the symptomatic quadrant? A. first B. second C. third D. last
D. last the nurse would systematically assess the abdomen concluding with the symptomatic area which is the area in which the client reports pain pain may be elicited in the symptomatic area if assessed first, second, or third, causing the muscles in other abdominal areas to tighten. This would interfere w/ the assessment
What color vomit is most concerning?
Dark brown it indicates the presence of stool or blood
What sound is generally heard over organs ?
Dullness upon percussion
What are the 4 steps of an abdominal assessment?
Inspection Auscultation Percussion Palpation
What action should the nurse take first when screening for any masses or tenderness?
Lightly palpate the abdominal surface allows the nurse to screen the abdomen for obvious masses or tenderness BEFORE applying deeper palpation
Are abdominal vascular/venous sounds normal?
No
Are rebound tenderness and involuntary rigidity normal findings?
No they should be notified to the HCP
Murphy's sign is __________ with palpation of _______ ______________
Pain with palpation of gall bladder (seen with cholecystitis)
Why does a duller sound occur at the right costal margin? Is this normal?
The Right Costal Margin is where the liver border is This is a normal sound
Liver failure is characterized by:
fluid in abdomen jaundice
Appendicitis; characterized by pain where?
inflammation of the appendix Characterized by RLQ pain
Cholecystitis; characterized by pain where?
inflammation of the gallbladder Characterized by RUQ pain, nausea, and vomiting after eating
What is CVA technique used to assess for?
inflammation of the kidney
peritonitis
inflammation of the peritoneum
gastroenteritis
inflammation of the stomach and intestines
Hypogastric
middle lower region below the umbilical region
What are symptoms of gastroenteritis?
nausea, vomiting, diarrhea
If a client has a history of nausea and vomiting, what is the priority assessment during oral care?
observe mucus membranes mucus membranes can indicate a FVD if there is excessive dryness
Ureteral colic
pain from a stone or blood clot in the ureter Characterized by flank pain that wraps around to the groin
What is rebound tenderness?
pain upon releasing the palpating hand pushing on the abdomen
Costo-vertebral angle Tenderness (CVA) is assessed by
percussing over the 12th rib placing one hand over the flank area and hitting the hand with pinky side of fist
hypoactive bowel sounds can be due to
peritonitis (inflamed lining of stomach)
How do you assess for rebound tenderness?
push down on the opposite side of the site of pain
What sound does the umbilical region make?
tympanic percussion
What sound is heard over most of the abdomen?
tympanic sounds
