ST Assessment of Abdomen PDF

Assessment of the Abdomen NURS 1090  Identify basic enteral tubes (nasogastric and enteral tubes). Unit Demonstrate basic Outcomes techniques to assess the abdomen. Identify physical assessment changes in the...

Assessment of the Abdomen NURS 1090  Identify basic enteral tubes (nasogastric and enteral tubes). Unit Demonstrate basic Outcomes techniques to assess the abdomen. Identify physical assessment changes in the older adult.  Abdominal Assessment Assessment includes an interview (obtaining a health history), inspection, auscultation, percussion, and palpation Includes the abdominal and pelvic areas Patients may be embarrassed by manifestations related to systems they consider “private” (ie: bowel function,genitourinary disorders) – Fear of loss of control of body functions adds to the stress the examination – The nurse must create an atmosphere of compassion, openness, and mutual trust Nursing History What information is important to know? Why do we need to know this?  Nursing History Description of current problem – Nausea, vomiting, dysphagia, indigestion or heartburn – Changes in stools or elimination patterns When was last BM? Fecal incontinence, constipation, diarrhea Use of laxatives Rectal bleeding, pain, tarry stools Be specific with questions : length of time, duration, frequency of symptoms  Symptoms of abdominal discomfort – Sense of “bloating” or distention; gas Appetite – Recent changes in appetite and/or dietary patterns Vegetarian diet Popular or fad diets Therapeutic diets Ethnic or religious influences Allergies and food sensitivities – Unplanned weight changes + or – 2 to 5 kg. Urinary symptoms Burning Urgency or incontinence Hematuria Menstrual History Pregnancy Last menstrual period Vaginal/penile discharge Perineal changes  Past medical history: note chronic and/or acute problems Surgical history and history of trauma to abdomen and pelvis Family medical history: of digestive problems Medications: Prescription , OTC, and herbals – OTC medications for heartburn and constipation—how often and for how long? History of alcohol use: – Why is this important?  Physical Exam Supplies: Stethoscope, adjustable light source, small pillows, tape measure and marking pencil Ask the patient to void/urinate prior to the exam Have the patient point to any areas of discomfort and assess them last  Make sure patient is warm with adequate gown/blanket to preserve privacy – Assure patient that no one will walk in during examination – The room must be quiet enough to hear subtle sounds during auscultation Assist patient to supine position with arms at their sides During the physical exam, use pillows to support the patient’s head and keep the patient’s knees slightly bent. – This helps reduce tension in the abdominal muscles Expose abdomen from chest to pubic area Order of Assessment: Inspection Stand at the patient’s side and look across the abdomen and at the foot of the patient and look toward the head – Symmetry Masses or irregularities – Visible aortic pulsations, peristalsis may be normal in thin people  Contour or shape: Should be symmetrical – Flat: normal – Rounded: obese – Scaphoid: emaciated, cachectic, thin – Protuberant: larger than rounded or moderate obesity – Distended: tight, www.biology-forums.com shiny skin (next slide) Skin – Pigmentation Even coloration Areas of ecchymosis – Veins: Liver disease may cause dilated superficial veins Ascites: fluid build- up in the abdomen. Tense, shiny skin may indicate ascites – May be associated with liver or heart problems Lesions and rashes Note location, size, and shape Striae Silver-white color Stretch marks Pregnancy, weight loss Scars Do the scars match the medical history? Umbilicus: – Protruding or inverted is normal – Note any bruising around umbilicus Hernia: Protrusion of abdominal organs/bowel through the muscle wall Hernias may cause upward protrusion of the Hernia.tripod.com umbilicus Tubes or drains – Document what infusing or draining Nasogastric Feeding tube Feeding Tube Nasogastric Tube Stoma – Surface opening on abdominal wall – Ostomy Surgically created opening between abdominal wall and intestine bowel or bladder type of appliance used drainage Ostomy  Abdominal Girth Girth or circumference around the abdomen – Measure abdominal girth: Place tape measure around abdomen at level of umbilicus If doing repeated measurements, mark both sides of the abdomen so each measurement is at same site Auscultation Done first after inspection because percussion and palpation may alter the nature of bowel sounds. Youtube.com Bowel Sounds Sounds caused by air mixing with fluid during peristalsis – Place diaphragm of stethoscope lightly on the abdomen Follow a regular pattern for listening: RLQ, RUQ, LUQ, LLQ Normal bowel sounds: are irregular, high-pitched, gurgling sounds – Usually heard 5-30 times per minute. Description of bowel sounds 1. Normal: audible 2. Hyperactive (borborygmi) High pitched, loud, rushing sounds that are frequent (every 3 seconds) May indicate increased intestinal motility Associated with cramping, diarrhea, an early bowel obstruction, or use of laxatives Description of Bowel Sounds 3. Hypoactive Extremely soft and infrequent Approximately 1-2 per minute 4. Absent Absent bowel sounds will not be able to be auscultated Auscultate in all four quadrants for a total of 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 – 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. – Percuss over each abdominal quadrant Percussion Sounds Tympany: heard over hollow organs in abdomen such as empty stomach or bowel Loud, hollow sound Dull: normal finding heard over solid organs such as the liver, spleen or other solid organ.  Palpation Use of light and deep touch to determine the size, shape, position, and tenderness of internal organs Ensure that patient’s position is appropriate for relaxation of the abdominal muscles, and warm the hands Light palpation: – Depress skin about ½ – 1” with your fingertips Make gentle rotating movements. Palpate all four quadrants, leaving painful or tender areas until last A “normal” abdomen is soft and non-tender Light palpation can help to determine some characteristics of skin and subcutaneous tissue Temperature, texture Abdominal distension Abnormalities such as superficial masses Also to determine areas of tenderness Note guarding or tensing of abdominal muscles May indicate pain or irritation of the peritoneum Note if muscles relax when the patient exhales Percussion of Urinary Bladder Used to assess the urinary bladder for urinary retention: Have patient attempt to empty bladder Patient should lie supine with abdominal muscles relaxed Percuss at the mid-line – Work upward from symphysis to umbilicus and back down – (Performed by advanced practitioner) – Note the point at which the sound changes from dull to tympanic – Dull: full bladder It is abnormal for the bladder to remain full after the patient attempts to empty it – Tympany Normal sound if the bladder is empty  Urinary Bladder Palpation Gently palpate midline above the pubic symphysis for a distended bladder. It will feel smooth, round, and tense The bladder is normally not palpable. www.biology-forums.com Older Adult: Expected Changes with Aging Weaker abdominal muscles – Decline in tone – Increase in adipose tissue – Results in rounder, more protruding abdomen Increased abdominal girth  Decreased saliva and gastric secretions Older Adult: Decreased gastric motility and peristalsis Expected Increased flatulence Changes Risk for constipation, impaction with Aging Less pain, guarding Peritoneal inflammation more difficult to detect Remember: Order of Abdominal Assessment** Inspection Auscultation Percussion Light Palpation