NURS 2030 Abdomen Assessment PDF

Assessment of Abdomen; GI System NURS 2030 Health Assessment The Keys to Assessing the Abdomen! 1. Use X-ray Vision! 2. Think Layers! a. b. c. d. e. f. Skin Subcutaneous Adipose Muscle Organs Vascular Landmarks for GI: Abdominal Muscles Organs of the abdominal cavity Nine vs. Four Quadrants Equipmen...

Assessment of Abdomen; GI System NURS 2030 Health Assessment The Keys to Assessing the Abdomen! 1. Use X-ray Vision! 2. Think Layers! a. b. c. d. e. f. Skin Subcutaneous Adipose Muscle Organs Vascular Landmarks for GI: Abdominal Muscles Organs of the abdominal cavity Nine vs. Four Quadrants Equipment Stethoscope Pen/Tape Ruler Reflex hammer to facilitate percussion Prep Client Empty bladder prior to exam Full exposure of abdomen (wear gown) Warm hands; short, clean nails Make the client comfortable Position supine arms at side, pillow under head and knees; or knees bend. Approach should be gentle and slow Remember Layers: Superficial to Deep Examine any tender areas last Exam Techniques Inspect but don’t touch Listen before touching Auscultate Percuss Palpate *LOOK, LISTEN, & FEEL! Inspection Don’t forget to think “layers” Symmetry – Symmetry: view from side and head Contour: – Contour: examine profile from rib margin to pubis Characteristics: – scars, striae, tautness, etc Abdominal Distention Generalized with obesity, enlarged organs, fluid or gas Umbilicus and above – pancreatic cyst, cancer Umbilicus to pubis – distended bladder, ovarian tumor, fibroid, pregnancy Asymmetric distention – hernia, tumor, cyst, obstruction, organ enlargement Don’t confuse a large abdomen with a distended abdomen The Pregnant Abdomen Inspection Have client take a deep breath and hold, contour should remain the same May see bulges not previously visible as the diaphragm lowers (Think of Organ Pathology) Color, Surface characteristics – – – – Consistent in color, uniform, may be paler Abnormal color: jaundice, bruises Ascites: glistening, taut appearance Cullen’s sign – periumbilical area bluish hemorrhage – Redness – inflammation – Striae: Result of pregnancy or weight gain. Recent, pink or blue, but turn silvery white Striae (stretch marks) Ascites Assessment Assessment for Ascites – Shifting dullness: Percuss abd with pt supine then turn pt onto one side & percuss again Dullness shifts to the dependent side – Fluid wave: With pt supine, ask another person to place ulnar surface of hand & forearm firmly along vertical midline of abd Place your hands on either side of abd & strike one side Feel for the impulse of the fluid wave Inspection Lesions – scars, rash (macules, papules, vesicles) Umbilicus – contour, location, position, inflammation or swelling – Centrally located or displaced, inverted or protruding Venous return patterns Venous return patterns – p 403 Healthy Portal Hypertension Inferior Vena Cava Obstruction Surgical Scar Inspection Inspect abdominal muscles to detect masses, hernia, separation Ask client to raise head  contraction of abdominal muscles; any superficial abdominal wall mass may become visible – Hernia: umbilical or incisional – Diastasis recti: separation of rectus muscle Hernias in various locations on abdomen Umbilical Hernia Umbilical Hernia Umbilical & Scrotal Hernias Inspection Surface motion & characteristics – Movement smooth and even with respiration – Peristalsis – rippling not usually visible except with obstruction – Aortic pulsation – visible with thin people; marked pulsation with aortic abdominal aneurysm; If seen, DO NOT PALPATE Auscultation Warm clean stethoscope Assess bowel motility with diaphragm Must listen for at least five full minutes before saying bowel sounds are absent Use an “S” motion and Think anatomy. “What anatomical structure am I listening over?” You will end up listening in all four quadrants with light pressure (Think of the organs you are over!) Note the frequency & character of bowel sounds – irregular clicks & gurgles Assess vascular sounds with bell Auscultation  Bowel sounds Increased pitch from obstruction Increased number – gastroenteritis  Vascular sounds Listen in epigastric region, and bilaterally in: aortic, renal, iliac, & femoral areas for any bruits or venous hums (epigastric region & around umbilicus) (Listen with BELL) Friction rub Liver & spleen indicates inflammation of peritoneal surface secondary to tumor or infection (Listen with DIAPHRAGM) Auscultate for Bruits & Venous Hums & Friction Rubs Abdominal Reflexes Assess after inspection & auscultation, but before palpation Expected finding: contraction of rectus muscle & pulling of umbilicus toward stroked side. Do not be alarmed if response/reaction is difficult to determine Percussion areas *Indirect in all areas to sense overall tympany or dullness. (Use “S” pattern) *Visualize and percuss over organs *Assess size, location & density of organs *Detect presence of fluid, air; masses that are fluid filled or solid Gastric Bubble Left epigastric area – lower louder pitch of tympany Direct for structure sounds Indirect percussion for tenderness Liver Borders Percuss: Right midclavicular line (RMCL) at area of tympany in right lower quadrant (RLQ) Percuss upward toward dullness & mark the lower border of the liver – usually at or slightly below costal margin (> 3 cm below costal margin, indicates enlargement of liver or displacement of diaphragm) – Mark the area *Percuss down RMCL from area of lung resonance until dullness and mark upper border; (usually 5th-7th ICS) Liver Span : 6-12cm Liver Borders Measure the distance between the two marks – MCL span 6-12 cm - normal – Greater than 12cm – Hepatomegaly (enlargement) – Less than 6cm - possible atrophy Check liver descent – Have client take deep breath and hold – Percuss upward along RMCL from RLQ to note tympany to dullness and compare from previous lower border mark – Should move down 2-3 cm Midsternal liver span 4-8 cm  Not used as much Scratch Method Splenic Dullness Just behind the left mid-axillary line Begin over abdomen tympany and percuss diagonally downward toward splenic dullness Usually between 6-10 intercostal space Document region! Palpation Think Layers! a. b. c. d. e. f. Skin Subcutaneous Adipose Muscle Organs Vascular Palpation Used to detect muscle spasm, masses, fluid & areas of tenderness. Abdominal organs for size, shape, mobility, etc. Stand on ® side of pt-patient’s knees flexed Light to moderate: (feeling in subq tissue & muscle of abdominal wall) (Visualize/Feel the different tissues) – Use palmar surface of fingers in all quadrants of abdomen; note muscular resistance, tenderness, masses. – “Depress ~1-2cm.”  Relative term (not applicable to obese ) – Note “guarding” or “rigidity” (board-like hardness) – Entire abdomen and umbilical ring – nodules or irregularities – Any tenderness not elicited on gentle palpation. For Sensitive (Ticklish) people, use their hand with yours Palpation Deep: (feeling under muscle into intra-abdominal cavity) – – – – – Palpate entire abdomen for masses Organs for enlargement Liver - two methods Gallbladder not usually palpable Spleen (be gentle) Why? Masses: Note location, size, shape, tenderness, pulsation, mobility. – Determine if superficial (in abdominal wall) or intra-abdominal - have patient lift head & tense muscles. If mass in abdominal wall, can still palpate. General Palpation of Abdomen Liver Palpation Bimanual Hook Method Palpation To palpate all organs, place nondominant hand under flank and press upward while using dominant hand to try to capture organ on deep inspiration Aortic pulsation Palpating the Kidney Left Kidney – On pt’s (L) side, place ® hand under pt’s (L) flank. – Place (L) hand at costal margin. – Push upward on flank as pt takes deep breath & palpate deeply, bringing hands together to feel kidney Palpating the Spleen Palpating aortic pulsation! CVA Tenderness Costal vertebral angle Palpate and Percuss Abnormal findings? Percuss for CVA tenderness Rebound Tenderness (McBurney’s Point) Iliopsoas muscle test A. The patient raises the leg from the hip while the examiner pushes downward against it. B. Alternate technique. The examiner hyperextends the right leg by drawing it backward while the patient lies on the left side Pain = Positive Iliopsoas sign Obturator muscle test With the right leg flexed at the hip and knee, rotate the leg laterally and medially. Pain = “Positive Obturator Test” Nutrition Nutritional assessment and intake for optimal health Anatomy and Physiology Food nourishes the body by supplying nutrients and calories to function in three ways: – Provide energy for necessary activities – Provide for building and maintaining body tissue – Regulate body processes The nutrients necessary to the body are classified as: – Macronutrients: carbohydrate, protein, fat – Micronutrients: vitamins, minerals, electrolytes – Water Nutrition and Growth Assessment Nutrition assessment – – – – Recent growth, weight loss, or weight gain Chronic illnesses affecting nutritional status or intake Medication and supplement use Assessment of nutrient intake Growth assessment – – – – – – Standing height (use stadiometer over age 2) Weight Calculation of BMI (over the age of 2) Waist circumference Waist-height ratio Waist-to-hip circumference ratio Nutrition: Macronutrients Carbohydrates (CHO): 1 gram = 4 calories – Body’s main source of energy – Recommended CHO content in diet, at least 55-65% Protein: 1 gram = 4 calories – Essential for life; builds & maintains tissue – 20 different amino acids, 9 essential (cannot be made by body) – Protein content of diet, 14-20% (some say up to 35%) Fat: 1 gram = 9 calories – Essential for normal growth & development; hormones; nerve transmission; energy – Recommended fat content of diet, 20-35% (lower best) Nutrition: Micronutrients Vitamins, minerals, & electrolytes – Required & stored in very small quantities – Vit K, Vit D, & Niacin metabolized by body; can’t metabolize other micronutrients. Water: – Person can only exist a few days without water – Adult body is 55-65% water – ~2–2.5 L of water lost daily through urine; lungs, perspiration (last two insensible loss) Nutritional History Present Problem: – Weight loss: Over what time period? desire/undesired, Preoccupation with wt., affect of medications. – Weight gain: Time period, sudden/gradual, medications – Increased metabolic requirements: Fever, infection, burns, pregnancy External loss: wounds, abscesses, chronic blood loss Nutritional History Past medical hx: – Chronic illnesses – Previous wt gain/loss, max/min wt. – Eating disorders Family hx: Personal/social: – – – – 24hr recall; nutritional supplements; Alcohol (1 gram = 7 calories) Income, ability to shop & prepare food Dentition Consider nutritional abnormalities: Obesity, Anorexia Nervosa, Bulimia Nervosa, FTT p. 127-130 Other Histories Family history Obesity, dyslipidemia Constitutionally short or tall stature Genetic or metabolic disorder: diabetes Eating disorder: anorexia, bulimia Alcoholism Personal and social history Nutrition Vitamins, minerals, supplements Usual weight and height Alcohol and drug use Food insecurity Functional assessment Typical mealtime situations Tube feedings, parenteral nutrition Dentition Adolescence CONCERNS: Faulty diets Supplements Laxative use Alcohol use Preoccupation with body Why Elderly Have Difficulty Getting Proper Nutrition? Loss of taste buds Decreased appetite Lack of money Dental problems Lack of motivation to cook Review on own: History of Special Populations Examination & Findings Body Mass Index: (text p 112-113) – Formula to assess nutritional status & total body fat – Normal for adults between 18.5-24.9 Over weight: 25-29.9 Obese: >30.0 – BMI= Wt in pounds (Ht in.) x (Ht in.) X 703 Example: man 6ft tall, wt. 185 (185 x 703) = 130,055 (72 x 72) = 5,184 130,055 ÷ 5,184 = 25.1 Exam findings Waist circumference: – A large waist circumference (>35” in women & >40” in men) associated with: risk type 2 diabetes, hypertension, dyslipidemia, metabolic syndrome, stroke, & ischemic cardiovascular disease. Waist to hip circumference ratio: – p. 100: >1.0 men & >.85 women = risk – Apple ( risk) vs Pear ( risk) body shape Apple vs Pear Body Shape 24 hr. Diet Recall 24 hr recall: (p 111) – List all foods, beverages by meals & snacks eaten over previous 24 hours with fluids; add up fluid totals – Quick & simple way of obtaining food history http://www.choosemyplate.gov -Food Guide and Resources https://www.learntobehealthy.org/ –Educational resources Nutrition 24 hours diet recall: – BK: 1 hard boiled egg, 1 slice whole wheat toast, 12oz coffee with milk & 1 tsp. sugar, 4oz OJ. Lunch: Hamburger with tomato, lettuce, mayo; large French fries, 1 large cookie, 8oz jello, 20oz diet coke. – Snack: 20oz chocolate milk shake – Dinner: Large bowl of chili with beans & meat; 12 saltine crackers, 10oz vanilla yogurt, 16oz water – Snack: 2 large pieces cheese pizza, 20oz Dr. Pepper at 10pm. – Total fluid intake: 100oz Fat soluble vitamins & deficiency Vitamin A – Night blindness, ↓resistance Xerophthalmia Corneal melting (kerotomalacia) Fat soluble vitamins & deficiency Vitamin D Rickets, Osteomalacia Vitamin K –Prolongs blood clotting; –lack of results in hemorrhage Water soluble vitamins & deficiency Vitamin B1 (thiamin) – Beriberi Niacin – Pellagra Vitamin B12 – Pernicious anemia Folate (folic acid) – Macrocytic anemia – Neural Tube Defects (Spina Bifida) Minerals Potassium: nerves, muscle contraction (Heart) – Almost all absorbed; excreted by kidneys – Deficiency: starvation or diuretic therapy Sodium: fluid, water & acid/base balance – Almost all absorbed; excreted kidneys & skin – Deficiency: rarely with excessive perspiration Minerals Calcium: healthy bones, teeth, nerves, enzymes, blood clotting, muscle contraction – 10-40% absorbed; aided in absorption by Vit. D – Deficiency: fragile bones; osteoporosis Iron: Hemoglobin of blood – 5-20% absorbed; acid & Vit. C aid absorption – Deficiency: anemia; cheilosis; pallor Hyperlipidemia Normal Total Cholesterol = 40mg/dL (High-density lipoprotein) (>60 protects heart!) LDL – Bad Cholesterol =