Podcast
Questions and Answers
What should be assessed last during a physical exam?
What should be assessed last during a physical exam?
Which of the following techniques is NOT important for ensuring patient comfort during a physical exam?
Which of the following techniques is NOT important for ensuring patient comfort during a physical exam?
What does shiny, tight skin on the abdomen potentially indicate?
What does shiny, tight skin on the abdomen potentially indicate?
During the physical examination, what is the appropriate contour of the abdomen that should be considered normal?
During the physical examination, what is the appropriate contour of the abdomen that should be considered normal?
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What aspect of skin assessment during a physical exam should be carefully noted?
What aspect of skin assessment during a physical exam should be carefully noted?
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What techniques are included in a comprehensive abdominal assessment?
What techniques are included in a comprehensive abdominal assessment?
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Why is it important to ask specific questions about gastrointestinal symptoms during the nursing history assessment?
Why is it important to ask specific questions about gastrointestinal symptoms during the nursing history assessment?
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How can a nurse create a comfortable atmosphere for patients during an abdominal assessment?
How can a nurse create a comfortable atmosphere for patients during an abdominal assessment?
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Which symptom would NOT typically be linked to gastrointestinal issues?
Which symptom would NOT typically be linked to gastrointestinal issues?
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What is an important consideration regarding a patient's family medical history in gastrointestinal assessments?
What is an important consideration regarding a patient's family medical history in gastrointestinal assessments?
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How frequently should a patient using over-the-counter medications for heartburn and constipation be questioned about their use?
How frequently should a patient using over-the-counter medications for heartburn and constipation be questioned about their use?
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Which dietary influence should a nurse consider when assessing a patient's appetite changes?
Which dietary influence should a nurse consider when assessing a patient's appetite changes?
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What symptom suggests a potential concern in gastrointestinal assessment regarding fecal elimination?
What symptom suggests a potential concern in gastrointestinal assessment regarding fecal elimination?
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What does a protruding umbilicus likely indicate?
What does a protruding umbilicus likely indicate?
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Which bowel sound is characterized by high-pitched, loud, rushing sounds and occurs every 3 seconds?
Which bowel sound is characterized by high-pitched, loud, rushing sounds and occurs every 3 seconds?
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When measuring abdominal girth, where should the tape measure be applied?
When measuring abdominal girth, where should the tape measure be applied?
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Why should auscultation of bowel sounds be done before percussion and palpation?
Why should auscultation of bowel sounds be done before percussion and palpation?
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What could absent bowel sounds suggest?
What could absent bowel sounds suggest?
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Which type of ostomy creates a surface opening on the abdominal wall?
Which type of ostomy creates a surface opening on the abdominal wall?
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What is a potential cause of hyperactive bowel sounds?
What is a potential cause of hyperactive bowel sounds?
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Which health professional is qualified to perform percussion of the abdomen?
Which health professional is qualified to perform percussion of the abdomen?
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Study Notes
Abdominal Assessment
- The examination includes: health history, inspection, auscultation, percussion, and palpation
- It includes the abdominal and pelvic areas
- Nurses should create an atmosphere of compassion, openness, and mutual trust
Nursing History
- Important information includes: nausea, vomiting, dysphagia, indigestion, heartburn, changes in bowel movements (frequency, consistency, color, etc.), use of laxatives, rectal bleeding, pain, tarry stools, bloating, distention, gas
- Appetite changes, recent changes in diet patterns, unplanned weight changes, urinary symptoms (burning, urgency, incontinence, hematuria), vaginal/penile discharge, perineal changes, menstrual history, and last menstrual period are also important.
- Past medical history, surgical history, family medical history, and medications (prescription, OTC, herbals) should be documented.
- History of alcohol use is important to help clinicians understand potential causes for liver problems.
Supplies
- Stethoscope, adjustable light source, small pillows, tape measure, and marking pencil
- Ask the patient to void prior to the exam
- Have the patient point to areas of discomfort and assess those last
- Ensure the patient is warm with adequate clothing or blankets to preserve privacy
- The room must be quiet enough to hear bowel sounds
- Assist the patient to a supine position with arms at their sides, use pillows to support the head and keep knees slightly bent to reduce abdominal muscle tension
Order of Assessment
- Perform inspection first, followed by auscultation, percussion, and palpation
- Stand at the patient’s side and look across the abdomen and at the foot, then look towards the head.
- Check for symmetry, masses, irregularities, visible aortic pulsations, and peristalsis.
Contour/Shape
- Should be symmetrical. Common shapes include:
- Flat: normal
- Rounded: obese
- Scaphoid: emaciated or cachectic
- Protuberant: larger than rounded, moderate obesity
- Distended: tight, shiny skin, may indicate ascites
Skin
- Should have even coloration.
- Check for areas of ecchymosis (bruising).
- Dilated superficial veins may be a sign of liver disease.
Ascites
- Ascites is fluid build-up in the abdomen
- May be associated with liver or heart problems.
Lesions and Rashes
- Note location, size, and shape.
- Striae (stretch marks) are silver-white marks and can be caused by pregnancy or weight loss.
- Check for scars and ensure they match the medical history.
Umbilicus
- A protruding or inverted umbilicus is normal.
- Note any bruising around the umbilicus.
Hernia
- A hernia is a protrusion of abdominal organs/bowel through the muscle wall
- Hernias may cause an upward protrusion of the umbilicus.
Tubes and Drains
- Document what is infusing or draining. This may include:
- Nasogastric tube (NG tube)
- Feeding tube
Stoma
- A stoma is a surface opening on the abdominal wall
- Ostomy is a surgically created opening between the abdominal wall and the intestine, bowel, or bladder.
- Note the type of appliance used and any drainage.
Abdominal Girth
- Measure around the abdomen at the level of the umbilicus.
- Use a tape measure and mark the abdomen on both sides to ensure repeated measurements are at the same site.
Auscultation
- Done first after inspection because percussion and palpation may alter bowel sounds.
Bowel Sounds
- Sounds caused by air mixing with fluid during peristalsis.
- Use the diaphragm of the stethoscope and listen in a regular pattern: RLQ, RUQ, LUQ, LLQ.
- Normal bowel sounds are irregular, high-pitched, gurgling sounds heard 5-30 times per minute.
Description of Bowel Sounds
- Normal: Audible
- Hyperactive (borborygmi): High-pitched, loud, rushing sounds heard frequently (every 3 seconds). May indicate increased intestinal motility. Associated with cramping, diarrhea, early bowel obstruction, or use of laxatives.
- Hypoactive: Extremely soft and infrequent sounds, approximately 1-2 per minute.
- Absent: Bowel sounds cannot be auscultated. Auscultate in all four quadrants for 3-5 minutes before concluding that bowel sounds are absent. Indicates cessation of intestinal motility. If possible, listen again after the patient has moved around and ask another nurse to listen.
Percussion
- Performed by an advanced practitioner
- Used to detect the size and location of abdominal organs or to detect air and fluid in the abdomen, stomach, or bowel.
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Description
This quiz covers key components of the abdominal assessment in nursing, including essential health history, inspection techniques, and the importance of creating a trusting environment. It emphasizes the significance of thorough documentation of symptoms, medical history, and lifestyle factors. Test your knowledge and understanding of these critical nursing practices.
