Elimination

light palpation

1 cm depth of palpation

deep palpation

5-6cm deep. detect subtle masses on organ

Cullen sign

A bluish or purple discoloration around the umbilicus (periumbilical ecchymosis) indicates intra-abdominal bleeding.

Gastroesophageal Reflux Disease (GERD)

A digestive disease that occurs when stomach acid or contents flow back into the esophagus. The backwash (reflux) irritates the lining of the esophagus, and, if left untreated, over time chronic esophageal irritation can lead to narrowing of the esophagus (esophageal stricture), esophageal ulcer, or Barrett esophagus.

Note their: Location, Size (cm), Shape, Consistency, Demarcation, Pulsatility, Tenderness, Mobility

A mass detected in any quadrant may be due to a tumor, cyst, abscess, enlarged organ, aneurysm, or adhesions. What should you note if you palpate a mass?

ascites

Abnormal accumulation of fluid in the abdomen. Usually results from liver failure or liver disease

hooking technique

An alternative method of palpating the liver is to stand up at the person's right chest. Hook your fingers over the costal margin from above. Ask the person to take a deep breath. Try to feel the liver edge bump your fingertips

A distended bladder is palpated as a smooth, round, and somewhat firm mass extending as far as the umbilicus. It may be further validated by dull percussion tones.

An empty bladder is neither palpable nor tender. To palpate the bladder,begin at the symphysis pubis and move upward and outward to estimate bladder borders. Describe abnormal findings.

Spleen

Approximately 7 cm wide and is located above the left kidney just below the diaphragm at the level of the ninth, tenth, and eleventh ribs. Typically not palpable. Functions primarily to filter the blood of cellular debris, to digest microorganisms, and to return the breakdown products to the liver.

Psoas Sign Pain in the RLQ (psoas sign) is associated with irritation of the iliopsoas muscle due to appendicitis (an inflamed appendix

Ask the client to lie on the left side. Hyperextend the client's right leg.

Assessing for Cholecytitis. Accentuated sharp pain that causes the client to hold his or her breath (inspiratory arrest) is a positive Murphy sign and is associated with acute cholecystitis.

Assess RUQ pain or tenderness, which may signal cholecystitis (inflammation of the gallbladder). Press your fingertips under the liver border at the right costal margin and ask the client to inhale deeply.

melena

Black tarry stool, following internal bleeding or the swallowing of blood

Normally, peristaltic waves are not seen, although they may be visible in very thin people as slight ripples on the abdominal wall

Can you observe peristaltic waves while inspecting the abdomen?

Use the diaphragm of the stethoscope apply light pressure and begin in the RLQ and proceed clockwise, covering all quadrants. We start at the RLQ bowel sounds are commonly heard at ileocecal valve. Note INTENSITY, PITCH AND FREQUENCY of bowel sounds. Bowel sounds originate from movement of air & fluid through small intestine. Confirm bowel sounds in each quadrant. Listen for up to 5 minutes (minimum of 1 minute per quadrant) to confirm the absence of bowel sounds.

Describe how to auscultate for bowel sounds in the abdomen

Normal = slight pulsation of the abdominal aorta, which is visible in the epigastrium, extends full length in thin people. Abnormal = Vigorous, wide, exaggerated pulsations may be seen with abdominal aortic aneurysm Ultrasound has high sensitivity and specificity and is the preferred screening modality for observing abdominal aortic pulses. Abdominal palpation has poor accuracy and is not recommended for screening

Describe normal and abnormal abdominal aortic pulsations

Lightly and systematically percuss all quadrants (13 spots) clockwise Tympany predominates over the abdomen because of air in the stomach and intestines Dullness is heard over the liver, spleen, and over a nonevacuated descending or sigmoid colon.

Describe percussion of the abdomen and where you should hear dullness or tympany.

peritoneum - parietal peritoneum outer - visceral peritoneum inner

Double-layered membrane surrounding the abdominal organs.

Alimentary tract controlled by ANS

GI tract. 27ft. Ingests and digests food. Absorbs nutrients nutrients, electrolytes, and water excretes waste products

Assess for rebound tenderness. If the client has abdominal pain or tenderness, test for rebound tenderness by palpating deeply at 90 degrees into the abdomen halfway between the umbilicus and the anterior iliac crest. Then suddenly release pressure. Listen and watch for the client's expression of pain. Ask the client to describe which hurt more—the pressing in or the releasing—and where on the abdomen the pain occurred Test for rebound tenderness should always be performed at the end of the examination Other appendicitis tests include Psoas sign, Obturator sign, and hypersensitivity test.

How could you test for appendicitis/peritoneal irritation? Also called Blumberg sign

1) have client empty their bladder 2) wear gown and lay arms at sides or crossed on chest (arms extended above head causes abdominal muscles to tense) 3) warm hands so hands are not cold on client 4) ask about painful or tender areas before palpating 5) ease anxiety by explaining each step and what you are doing

How should one prepare the client before assessing their abdomen?

Use the bell to listen for bruits (low-pitched murmurs) over the abdominal aorta and renal, iliac, and femoral arteries. Also listen for venous hum(bell), and hepatic or splenic friction rub(diaphragm). Auscultating for vascular sounds is especially important if the client has hypertension or if you suspect arterial insufficiency to the legs.

How should the nurse auscultate for vascular sounds? In what clients is it particularly important to listen for vascular sounds?

It should be firm, smooth, and even. A hard, firm liver may indicate cancer A liver more than 1-3 cm below the costal margin is considered enlarged (unless displaced by the diaphragm).

If the lower edge of the liver is palpable, what should it feel like?

Test for Shifting Dullness. When ascites is present and the client is supine, the fluid assumes a dependent position and produces a dull percussion tone around the flanks. Air rises to the top and tympany is percussed around the umbilicus. When the client turns onto one side and ascites is present, the fluid assumes a dependent position and air rises to the top. Performing the Fluid Wave Test A second special technique to detect ascites is the fluid wave test. The client should remain supine. You will need assistance with this test. Ask the client or an assistant to place the ulnar side of the hand and the lateral side of the forearm firmly along the midline of the abdomen. Firmly place the palmar surface of your fingers and hand against one side of the client's abdomen. Use your other hand to tap the opposite side of the abdominal wall. Movement of a fluid wave against the resting hand suggests large amounts of fluid are present (ascites). Because this test is not completely reliable, definitive testing by ultrasound is needed.

If you suspect that the client has ascites because of a distended abdomen or bulging flanks, what should your perform? What is an additional test to perform?

Involuntary reflex guarding is serious and reflects peritoneal irritation. The abdomen is rigid and the rectus muscle fails to relax with palpation when the client exhales. The nurse suspects a hernia if a protrusion appears on the client's abdomen when the nurse asks the client to cough or bear down. Involuntary reflex guarding is a sign of peritoneal irritation and the client should be assessed further for possible infection.

Light palpation is used to identify areas of tenderness and muscular resistance. Keep in mind that the rectus abdominis muscle relaxes on expiration. Involuntary reflex guarding is serious and reflects what?

1) Secretes erythropoietin - stimulates RBC production 2) Secretes renin - raises BP by narrowing/constricting blood vessels 3) produces vitamin D 4) Nephron regulates fluid and electrolyte balance by producing urine

List some functions of the kidneys

1) eat 5-6 small meals instead of 3 large ones 2) eat slowly and chew food well 3) do not lay down after eating, remain upright for 2 hours 4) try sleeping on left side (this helps because of gravity, the shape of the stomach, and the angle of the connection between it and the esophagus.) 5) sleep with HOB raises 6-8in 6) avoid reflux producing foods (coffee, tea, tomato based foods, citrus fruits and juices, and chocolate/sweets) 7) Avoid foods that cause you to swallow air, such as chewing gum, sucking hard candy, or drinking sodas

List some patient teaching for a client with GERD

1) Wash hands frequently with soap and water. 2) eat completely cooked foods. 3) Avoid excessive alcohol intake (more than one drink per day for women and two drinks per day for males). 4) Avoid or stop smoking and chewing tobacco.

List some patient teaching for a client with PUD

1) maintain healthy weight 2) exercise regularly 3) good toileting habits 4) avoid delayed voiding/defecating 5) drink plenty of fluids (2,000-3,000mLs daily) 6) no smoking

List some ways to promote health regarding elimination

right upper (RUQ) left upper (LUQ) right lower (RLU) left lower (LLQ)

List the 4 abdominal quadrants

Pancreas

Located mostly behind the stomach deep in the upper abdomen, is normally not palpable. It is a long gland extending across the abdomen from the RUQ to the LUQ. It has two functions: it is an endocrine gland and an accessory organ of digestion

urinary frequency

Means needing to urinate more often than usual.

Normal = New striae are pink or bluish in color; old striae are silvery, white, linear, and uneven stretch marks from past pregnancies or weight gain Abnormal = Dark bluish-pink striae are associated with Cushing syndrome.

Note any striae/stretchmarks in an abdominal assessment. What are normal and abnormal findings?

Rovsing sign

Pain in the RLQ during pressure in the LLQ Acute appendicitis

Postoperatively, bowel sounds resume gradually depending on the type of surgery. Small intestine = first few hours postoperatively Stomach emptying takes 24-48 hours to resume Colon requires 3-5 days to recover propulsive activity.

Postoperatively, when does the small intestine, stomach, and colon begin to function normally?

hernia

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

abdominal aorta

Pulsations of the aorta are frequently visible and palpable midline in the upper abdomen. The aorta branches into the right and left iliac arteries just below the umbilicus. Pulsations of the right and left iliac arteries may be felt in the RLQ and LLQ

Palpating the spleen A palpable spleen suggests enlargement (up to three times the normal size), which may result from infections, trauma, mononucleosis, chronic blood disorders, and cancers.

Stand at the client's right side, reach over the abdomen with your left arm, and place your hand under the posterior lower ribs. Pull up gently. Place your right hand below the left costal margin with the fingers pointing toward the client's head. Ask the client to inhale and press inward and upward as you provide support with your other hand

hypersensitivity test Pain or an exaggerated sensation felt in the RLQ is a positive skin hypersensitivity test and may indicate appendicitis.

Stroke the abdomen with a sharp object (e.g., broken cotton tipped applicator or tongue blade) or grasp a fold of skin with your thumb and index finger and quickly let go. Do this several times along the abdominal wall

Obturator Sign Pain in the RLQ indicates irritation of the obturator muscle due to appendicitis or a perforated appendix

Support the client's right knee and ankle. Flex the hip and knee, and rotate the leg internally and externally

Stomach

The abdominal cavity begins with the? It is not normally palpable

linea alba

The joining of the abdominal muscle fibers at the midline of the abdomen forms a white line called the? This extends vertically from the xiphoid process of the sternum to the symphysis pubis

Liver If palpable, should have a soft consistency

The liver functions as an accessory digestive organ and has a variety of metabolic and regulatory functions as well. Stores iron and glucose, forms clotting factors/blood plasma proteins. produces cholesterol, urea, and forms bile. Also breaks down damaged or old red blood cells.

Fat Feces Fetus Fibroids Flatulence Fluid

The major causes of abdominal distention are sometimes referred to as the "6 Fs". What are the 6 F's?

liver percussion normal liver span at MCL = 6-12cm normal liver span at MSL (mid sternal line) = 4-8 cm.

To assess the lower border, begin in the RLQ at the MCL and percuss upward. Note the change from tympany to dullness. Mark this point. To assess the upper border, percuss over the upper right chest at the MCL and percuss downward, noting the change from lung resonance to liver dullness. Mark this point. Measure the distance between the two marks: this is the span of the liver. What is the normal liver span?

Bladder Uterus Prostate gland

What abdominal organs are located along the midline

Solid 1) liver 2) pancreas 3) spleen 4) adrenal glands 5) kidneys 6) ovaries 7) uterus Hollow 1) stomach 2) gallbladder 3) urinary bladder 4) small intestine 5) large intestine

What are 7 solid viscera and 5 hollow viscera?

hyperresonance is heard over a gaseous distended abdomen Abnormal dullness is heard over a distended bladder, large masses, or ascites. Enlarged spleen or enlarged liver also dull

What are some examples of abnormal percussion findings?

hoarseness laryngitis chronic dry cough asthma or worsening of asthma symptoms feeling as if there is a lump in the throat sudden increase in saliva bad breath (halitosis) earaches chest pain or discomfort (seek emergency care for chest pain)

What are some symptoms of GERD (gastroesophageal reflux disease)?

1) burning sensation that often wakes the client in the night, and is worse on an empty stomach 2) feeling of fullness that leads to reduced fluid and food intake, hunger, an empty feeling 1-3 hours after a meal, or mild nausea. 3) Chest pain, fatigue, weight loss, black or tarry stools, and vomiting, which may be bloody

What are some symptoms of PUD (peptic ulcer disease)?

1) external abdominal oblique 2) internal abdominal oblique 3) transverse abdominins

What are the 3 layers of abdominal muscle from outermost to innermost?

1) parietal - parietal peritoneum becomes inflamed, as in appendicitis or peritonitis. This type of pain tends to localize more to the source and is characterized as a more severe and steady pain 2) visceral - dull, aching, burning, cramping, or colicky pain of hollow organ 3) referred - pain that travels, or refers, from the primary site and becomes highly localized at the distant site

What are the 3 types of abdominal pain? Describe each one.

1) Right hypochondriac region 2) Epigastric region 3) Left hypochondriac region 4) Right lumbar region 5) Umbilical region 6) Left lumbar region 7) Right iliac (inguinal) region 8) Hypogastric region 9) Left iliac (inguinal) region

What are the 9 regions of the abdomen?

Helicobacter pylori many people have H. pylori with no disease whatsoever

What bacterium is active in causing peptic or gastric ulcers?

A deviated umbilicus may be caused by pressure from a mass, enlarged organs, hernia, fluid, or scar tissue

What can cause a deviated umbilicus?

Decreased or absent bowel sounds signify the absence of bowel motility, which constitutes an emergency requiring immediate referral. peritonitis or paralytic ileus

What does absent or decreased bowel sounds indicate?

Inspect, Auscultate, Percuss, Palpate You should Auscultate before percussing or palpating because percussing and palpating can alter client's bowel sounds

What is the correct assessment sequence of the abdomen?

Solid viscera = organs that maintain their shape consistently Hollow viscera = organs that change shape depending on their contents.

What is the difference between solid viscera and hollow viscera?

A series of intermittent, soft clicks and gurgles are heard at a rate of 5-30 per minute. Bowel sounds normally occur every 5-15 seconds borborygmus = a hyperactive bowel sound characterized by loud, prolonged gurgles characteristic of one's "stomach growling."

What is the normal rate for bowel sounds? What is borborygmus?

Left kidney (lower pole) Left ovary and tube Left ureter Left spermatic cord Descending and sigmoid colon

What organs reside in the LLQ?

Left adrenal gland Left kidney (upper pole) Left ureter Pancreas (body and tail) Spleen Splenic flexure of colon Stomach Part of the transverse & descending colon

What organs reside in the LUQ?

Appendix Ascending colon Cecum Right kidney (lower pole) Right ovary and fallopian tube Right ureter Right spermatic cord

What organs reside in the RLQ?

Liver Part of the ascending and transverse colon Gallbladder Pancreas head Right adrenal gland Right kidney (upper pole) Right ureter duodenum pyloric sphincter

What organs reside in the RUQ?

Do not palpate a pulsating midline mass; it may be a dissecting aneurysm that can rupture from the pressure of palpation. Also avoid deep palpation over tender organs as in the case of polycystic kidneys, Wilms tumor, transplantation, or suspected splenic trauma.

What should you keep in mind when palpating areas of caution?

Abdominal pain? Indigestion? Nausea/Vomiting? Appetite? How often they have a BM and then description of the stool. If yes to any, COLDSPA

What subjective questions should you ask a patient during an elimination/abdominal interview?

The right kidney is positioned slightly lower because of the position of the liver. Therefore, in some thin clients, the bottom portion of the right kidney may be palpated anteriorly

Why is the right kidney slightly lower than the left?

tangential lighting

a source of illumination directed from an angle to the side of what is being examined; used to make a raised lesion cast a shadow, for example

scaphoid can be normal or abnormal

abnormally sunken abdominal wall, as with malnutrition or underweight.

Anuria

absence of urine < 50mL in 24hrs

costovertebral angle

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

halitosis

bad smelling breath

hematochezia

blood in stool

symphysis pubis (pubic symphysis)

cartilaginous joint (a joint made of hyaline cartilage and fibrocartilage) located between the left and right pubic bones near the midline of the body

gallbladder

concentrates and stores the bile needed to digest fat. It is located near the posterior surface of the liver lateral to the MCL. It is not normally palpated because it is difficult to distinguish between the gallbladder and the liver

High pitched, gurgling, cascading sounds. - use diaphragm

describe the characteristics of normal bowel sounds

urinary hesitancy

difficulty in starting a urinary stream

Grey Turner's sign

discoloration over the flanks suggesting intra-abdominal bleeding. possibly from trauma to the kidneys, pancreas, or duodenum or from pancreatitis.

Polydipsia

excessive thirst

nocturia

excessive urination at night

Polyuria

excessive urination in large amounts

steatorrhea

fat in the feces

urgency

feeling the need to urinate immediately

diarrhea

frequent passage of loose, watery stools

flatulence

gas in the stomach or intestines

neurogenic bladder

impairment of bladder control due to brain or nerve conduction

Diuresis (polyuira)

increased output of urine

Cholecystitis

inflammation of the gallbladder

Murphy sign - inflammed gallbladder Pain elicited when pressure is applied under the liver border at the right costal margin and client inhales deeply.

is used to detect inflammation of the gallbladder (cholecystitis)

small intestine

lies coiled in all four quadrants of the abdomen, is not normally palpated.

xiphoid process

lower, narrow portion of the sternum

petechiae

minute hemorrhagic spots of pinhead to pinpoint size

diastasis recti

occurs when the bowel protrudes through a separation between the two rectus abdominis muscles. It appears as a midline ridge. The bulge may appear only when the client raises the head or coughs. The condition is of little significance

epigastric hernia

occurs when the bowel protrudes through a weakness in the linea alba. The small bulge appears midline between the xiphoid process and the umbilicus. It may be discovered only on palpation.

keloid

overgrowth of scar tissue

dysuria

painful or difficult urination

Kidneys

posterior organs near the level of the T12 to L3 vertebrae. Filters blood from renal arteries and produces urine as waste

Blumberg sign

rebound tenderness

oliguria

small amounts of urine < 240-400mLs urine in 24hrs

Fluid wave test

tests for ascites, shifting dullness is another test to test for ascites.

hydronephrosis

the dilation (swelling) of one or both kidneys

Peptic Ulcer Disease (PUD) if peptic ulcers are left untreated, they can result in internal bleeding, infection, and scar tissue.

ulcers, or open sores, that form in the lining of the esophagus, stomach, or small intestine when acid eats away the protective mucous covering and erodes the underlying lining of these organs

hematemesis

vomiting blood

1) salivary glands 2) liver 3) pancreas 4) gallbladder

what are the 4 accessory digestive organs?

kidney infection (pyelonephritis), renal calculi, or hydronephrosis

what does sharp pain at the costovertebral angles (CVA) during blunt percussion of the kidneys indicate?

If the client is older than age 50 or has hypertension, assess the width of the aorta

what is an older adult consideration regarding the abdominal aorta?