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Lecture 7 Denver School of Nursing Fall 2013 K.Hendrickson PhD, RN

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1 Lecture 7 Denver School of Nursing Fall 2013 K.Hendrickson PhD, RN
Health Assessment Lecture 7 Denver School of Nursing Fall 2013 K.Hendrickson PhD, RN

2 Abdomen and Gastrointestinal System
Chapter 13 Abdomen and Gastrointestinal System

3 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
A&P: Abdominal Cavity Kidneys Ureters Bladder Adrenal glands Major vessels Women: Uterus, fallopian tubes, ovaries Stomach Small and large intestines Liver Gallbladder Pancreas Spleen

4 Anatomy and Physiology
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Anatomy and Physiology Esophagus lies outside abdominal cavity but is vital part of gastrointestinal (GI) system.

5 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

6 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

7 A&P: Peritoneum, Musculature, & Connective Tissue
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. A&P: Peritoneum, Musculature, & Connective Tissue Peritoneum: serous membrane forming a protective cover. Divided into two layers: Parietal peritoneum lines abdominal wall. Visceral peritoneum covers organs. Peritoneal cavity is space between parietal & visceral layers. Contains serous fluid that reduces friction between organs and membranes.

8 A&P: Peritoneum, Musculature, & Connective Tissue
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. A&P: Peritoneum, Musculature, & Connective Tissue Rectus abdominis muscles form anterior border. Vertebral column and lumbar muscles form posterior border. Internal and external oblique muscles provide lateral support External oblique aponeurosis is strong membrane covering entire ventral surface of abdomen; lies superficial to rectus abdominis. Fibers from both sides interlace in midline to form linea alba. Linea alba is tendinous band protecting midline of rectus abdominis muscles from xiphoid process to symphysis pubis. Diaphragm forms superior border of abdomen. Superior aperture of lesser pelvis forms inferior border.

9 Anatomy & Physiology: Alimentary Tract
Alimentary tract extends from mouth to anus, 27 feet (8.2 meters) & includes: Esophagus Stomach Small and large intestines Rectum Anal canal Main functions are to: Ingest and digest food. Absorb nutrients, electrolytes, and water. Excrete waste products. Peristalsis moves products of digestion: Controlled by autonomic nervous system.

10 Anatomy and Physiology: Esophagus
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Anatomy and Physiology: Esophagus A tube about 10 inches long. Connects pharynx to the stomach. Usual pH is between 6 and 8. Esophageal contents enter stomach through lower esophageal sphincter and mix with digestive enzymes and hydrochloric acid.

11 Anatomy and Physiology: Stomach
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Anatomy and Physiology: Stomach Hollow, flask-shaped, muscular organ directly below diaphragm in LUQ. Esophageal contents enter stomach through lower esophageal sphincter & mix with digestive enzymes & HCL. Gastric acid continues breakdown of carbohydrates that begin in mouth. Pepsin breaks down proteins to peptones & amino acids. Gastric lipase acts on emulsified fats—triglycerides to fatty acids or glycerol. Liquefies food into chyme & moves it into duodenum of small intestine. Usual pH of stomach from 2 to 4. Pyloric sphincter regulates outflow of chyme into duodenum.

12 Anatomy & Physiology: Small Intestine
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Anatomy & Physiology: Small Intestine Longest section of alimentary tract is about 21 feet. Begins at pyloric orifice, joins large intestine at ileocecal valve. Ingested food mixed, digested, and absorbed. Divided into three segments: Duodenum occupies first foot (30 cm) and forms C-shaped curve around head of pancreas. Jejunum (8 feet long) and ileum (12 feet long) provide absorption through intestinal villi. Ileocecal valve, between ileum and large intestine, prevents backward flow of fecal material.

13 A&P: Large Intestine (Colon) & Rectum
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. A&P: Large Intestine (Colon) & Rectum Large intestine is 5 feet long & consists of cecum, appendix, colon, rectum, & anal canal. Ileal contents empty into cecum via ileocecal valve. Appendix extends from base of cecum. Colon is divided into three parts: ascending, transverse, & descending. End of descending colon turns medially and inferiorly to form S-shaped sigmoid colon. Rectum extends from sigmoid colon to pelvic floor, continues as anal canal, ends at anus. Large intestine absorbs water and electrolytes. Feces formed in large intestine and held until defecation.

14 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
A&P: Accessory Organs Accessory organs of GI tract: Salivary glands Liver Gallbladder Pancreas

15 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
A&P: Liver Liver is largest organ (weighing 3.5 pounds) in body. Under right diaphragm, from fifth intercostal space to below costal margin. Substantial portion covered by rib cage, only lower margin exposed beneath it. Composed of right and left lobes.

16 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
A&P: Liver Liver functions: Bile production and secretion to emulsify fat. Transfer of bilirubin from blood to duodenum. Metabolism of proteins, carbohydrates, and fats Storage of glucose in form of glycogen. Production of clotting factors and fibrinogen for coagulation. Synthesis of plasma proteins (albumin/globulin). Detoxification of substances, including drugs and alcohol. Storage of minerals (iron and copper) and vitamins (A, B12, and B-complex vitamins).

17 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
A&P: Gallbladder Gallbladder is pear-shaped sac, 3 inches long, inferior to surface of liver. Concentrates and stores bile produced in liver. Cystic duct joins hepatic duct, forming common bile duct that drains bile into duodenum. Bile in feces causes brown color.

18 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
A&P: Pancreas Pancreas located in upper left abdominal cavity, under left lobe of liver, behind stomach. Has both endocrine and exocrine functions: Endocrine secretions include insulin, glucagon, & gastrin for carbohydrate metabolism. Exocrine secretions contain bicarbonate and pancreatic enzymes that break down proteins, fats, and carbohydrates in duodenum for absorption.

19 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
A&P: Spleen Spleen is highly vascular, concave, encapsulated organ in upper left quadrant of abdomen. Part of lymphatic system, composed of two systems: White pulp consisting of lymphatic nodules and diffuse lymphatic tissue. Red pulp consisting of venous sinusoids.

20 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
A&P: Spleen Functions of spleen: Storage of 1% to 2% of erythrocytes and platelets. Macrophages remove old and agglutinated erythrocytes and platelets. Activation of B and T lymphocytes. Production of erythrocytes during bone marrow depression.

21 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
A&P: Urinary Tract Kidneys, ureters, urinary bladder, and urethra work together to remove water-soluble wastes. Kidneys: Located in posterior abdominal cavity on either side, covered by peritoneum and attached to posterior abdominal wall. Partially protected by ribs and cushion of fat and fascia. Right kidney slightly lower than left, due to displacement by liver. Kidney functions include: Secretion of erythropoietin to stimulate red blood cell production. Secretion of renin to activate renin-angiotensin-aldosterone system (constricts blood vessels and affects blood pressure). Production of biologically active form of vitamin D. Nephron regulates fluid and electrolyte balance through elaborate microscopic filter and pressure system that eventually produces urine.

22 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
A&P: Ureters & Bladder Ureters: Urine forms in nephron, flows from distal tubes & collecting ducts into ureters and into bladder. Composed of long, intertwining muscle bundles extending 12 inches to insertion at base of bladder. Bladder, a sac of smooth muscle fibers, behind symphysis pubis in anterior half of pelvis. Contains internal sphincter that relaxes when bladder full. When bladder’s volume reaches about 300 mL, moderate distention is felt; a level of 450 mL causes discomfort. For voiding to occur, external sphincter relaxes voluntarily, and urine exits through urethra, which extends out of base to external meatus. * Nurses check for at no more than 30 cc residual urine after foley removal

23 A&P: Vasculature of the Abdomen
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. A&P: Vasculature of the Abdomen Descending aorta travels through diaphragm and branches into two common iliac arteries at level of umbilicus. Kidney perfusion provided by right and left renal arteries that branch off descending aorta. Blood from abdomen returned to right side of heart by inferior vena cava. Several veins empty into inferior vena cava. Hepatic portal system: Veins draining intestines, pancreas, stomach, and gallbladder. Renal veins drain kidneys and ureters.

24 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

25 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

26

27 Abdominal Assessment

28 General Health History: Present Health Status
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. General Health History: Present Health Status Any chronic diseases that affect your GI or urinary systems? Do you take any medications? What, and how often? Taking as prescribed? How often do you have a bowel movement? What are color and consistency of stool? NEVER underestimate the importance of this!!!

29 General Health History: Past Medical History
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. General Health History: Past Medical History Have you had problems with abdomen or digestive system? Surgery of abdomen or urinary tract? Change in routines, changes in food, or bowel or urinary elimination? Able to cope with the presence of ostomy? Have you had problems with your urinary tract in the past? Do you experience leakage of urine? When does this occur?

30 General Health History: Family History
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. General Health History: Family History Family history of diseases of GI system: Gastroesophageal reflux disease (GERD)? Peptic ulcer disease? Stomach or colon cancer? Family history of diseases of urinary tract such as kidney stones? Kidney or bladder cancer?

31 General Health History: Personal and Psychosocial History
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. General Health History: Personal and Psychosocial History Do you smoke? How much? How long have you been smoking? Have you considered stopping? Do your drink alcohol? How much? How often?

32 Problem-Based History: Abdominal Pain
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Problem-Based History: Abdominal Pain Pain associated with other symptoms? Stress? Fatigue? Nausea and vomiting? Gas? Constipation or diarrhea? How long have you had pain? Where? When did you first feel pain? Constant or intermittent? Had episodes before? Did pain start suddenly? Changed location? Felt elsewhere? Worse when stomach empty? Affected by eating? Worse at night or day? Women: Associated with menstrual period? Last menstrual period? Could you be pregnant?

33 Problem-Based History: N&V
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Problem-Based History: N&V Nausea or vomiting for how long? Frequency? How much vomit? What does it look like? Contain blood? Do you have nausea without vomiting? Foods eaten in last 24 hours? How long after eating did you vomit? Anyone else had these symptoms over same period? Other symptoms: Pain? Constipation? Diarrhea?

34 Problem-Based History: Indigestion
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Problem-Based History: Indigestion Indigestion or heartburn for how long? Stomach? Chest? What makes it worse? Change of position? What relieves pain? Antacids or acid blockers? Other symptoms: Radiating pain? Sweating? Lightheadedness?

35 Problem-Based History: Abdominal Distention
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Problem-Based History: Abdominal Distention How long have you had it? Does it come and go? Is it related to eating? What relieves it? Other symptoms: Vomiting? Loss of appetite? Weight loss? Change in bowel habits? Shortness of breath? Pain?

36 Problem-Based History: Change in Bowel Habits
Describe change. When did you first notice change? Changed diet? What does stool look like? Bloody, mucoid, fatty, watery? Other symptoms: Increased gas? Pain? Nausea or vomiting? Abdominal cramping? Diarrhea?

37 Problem-Based History: Yellow Discoloration of Eyes or Skin (Jaundice)
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Problem-Based History: Yellow Discoloration of Eyes or Skin (Jaundice) First noticed when? Has it become more noticeable? Associated with abdominal pain? Loss of appetite Nausea or vomiting? Blood transfusion or tattoos in past year? Use intravenous drugs? Eat raw shellfish such as oysters? Traveled abroad in last year? Has color of your urine or stools changed?

38 Problem-Based History: Problems with Urination
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Problem-Based History: Problems with Urination Usual pattern of urination? Pain or burning? Frequency or urgency? Associated symptoms: Fever? Chills? Back pain? Blood in urine? Unexpected weight gain? Swelling in ankles at end of day or shortness of breath? Urinating less?

39 Abdomen: Physical Exam
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Abdomen: Physical Exam

40 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Physical Exam OBSERVE General behavior and position INSPECT Abdomen AUSCULTATE All 4 quadrants PALPATE Light palpation ONLY PERCUSS Liver, spleen, kidneys Other Assess fluid, pain r/t inflammation, floating mass, abdominal reflexes

41 INSPECT: general appearance & position
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. INSPECT: general appearance & position Observe patient’s general behavior and position. Inspect abdomen for skin color, surface characteristics, contour, and surface movements. Surface characteristics should be smooth, with centrally located umbilicus. Striae, scars, faint vascular network. Contour usually sunken; slight protrusion if overweight or obese.

42 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
AUSCULTATE Auscultate abdomen for bowel sounds: Use diaphragm of stethoscope lightly and listen in a systematic progression. Auscultate abdomen for arterial and venous vascular sounds: Use bell of stethoscope over aorta, renal, iliac, and femoral arteries for bruits. Use bell over epigastric area or around umbilicus for venous hum.

43 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

44 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
PALPATE Palpate abdomen lightly for tenderness, muscle tone, and surface characteristics. No tenderness should be present, and the abdominal muscles should be relaxed. Palpate abdomen deeply for tenderness, masses, and aortic pulsation. NO- for advanced practice only. Observe for facial grimaces that indicate areas of tenderness; ask patient to breathe slowly through mouth to facilitate muscle relaxation; when patient has abdominal pain, palpate over area of pain last.

45 Purcussion & common tests
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Purcussion & common tests Percuss all quadrants of abdomen using indirect percussion to assess density of abdominal contents. Assess abdomen for fluid, if fluid is suspected. Assess abdominal pain due to inflammation. Test for rebound tenderness. McBurney’s sign: Test for appendicitis. Iliopsoas muscle test: If acute appendicitis suspected. Obturator muscle test: If ruptured appendix or pelvic abscess suspected.

46 Tests for Ascites Shifting Dullness Fluid Wave

47 Tests for Appendicitis
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Tests for Appendicitis Rebound Tenderness McBurney’s Sign Iliopsoas Muscle Test Obturator Muscle Test

48 Special Circumstances & Advanced Practice
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Special Circumstances & Advanced Practice Percuss liver to determine span and descent. Liver span correlates with body size and gender; large people and men tend to have larger spans; lower border of liver should descend downward 0.75 to 1.25 inches (2 to 3 cm). Percuss spleen for size. Note whether tympany changes to dullness on inspiration; enlarged spleen is brought forward on inspiration to produce a dull percussion note. Palpate around umbilicus for bulges, nodules, and umbilical ring. Ring should be round with no irregularities or bulges. Umbilicus should be inverted or slightly everted. Palpate liver for lower border and tenderness.

49 Special Circumstances & Advanced Practice
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Special Circumstances & Advanced Practice Palpate gallbladder for tenderness. Palpate spleen for border and tenderness. Palpate kidneys for presence, contour, and tenderness. Elicit abdominal reflexes for presence. Percuss kidneys for costovertebral angle tenderness.

50 Special Circumstances & Advanced Practice
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Special Circumstances & Advanced Practice Assess abdomen for floating mass. Ballottement is palpation technique used to determine a floating mass. Ballottement can be performed with one or both hands.

51 Age-Related Variations: Infants, Children, and Adolescents
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Age-Related Variations: Infants, Children, and Adolescents Assessment techniques are same for infants, children, and adolescents. There are several differences in assessment findings in infants based on anatomic differences. Children and adolescents may resist abdominal palpation because they are ticklish.

52 Age-Related Variations: Older Adults
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Age-Related Variations: Older Adults Procedures and techniques for assessing GI and renal systems of older adults are same as for younger adults.

53 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Pathophysiology

54 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
GERD GERD: Flow of gastric secretions up into esophagus. Weakened lower esophageal pressure or increased intraabdominal pressure. Clinical findings: Heartburn Regurgitation Dysphagia

55 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Hiatal Hernia Hiatal hernia: Protrusion of stomach through esophageal hiatus of diaphragm into mediastinal cavity. Muscle weakness is a primary factor. Pregnancy, obesity, and ascites. More common in women and older adults. Clinical findings: Clinical manifestations are same as those of GERD: Heartburn Regurgitation Dysphagia

56 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Peptic Ulcer Disease Peptic ulcer disease is ulcer occurring in lower end of esophagus, stomach, or duodenum. Duodenal ulcer most common, from break in mucosa that forms scar. Gastric and duodenal ulcers may result from infection with Helicobacter pylori infection. Gastric ulcers also caused by stress, medications (corticosteroids, aspirin, nonsteriodal antiinflammatory drugs [NSAIDs]). Patients complain of burning after eating.

57 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

58 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Crohn’s Disease Crohn’s disease—chronic inflammatory bowel disease (IBD)—is also called regional enteritis or regional ileitis. Inflammation may occur from mouth to anus; commonly affects terminal ileum and colon. Affected mucosa ulcerated with fistulas, fissures, and abscesses. Clinical findings: Patients complain of severe abdominal pain, cramping, diarrhea, nausea, fever, chills, weakness, anorexia, and weight loss.

59 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Ulcerative Colitis Ulcerative colitis, a chronic IBD, starts in rectum and progresses through large intestine. Submucosa becomes engorged; mucosa ulcerated and denuded with granulation tissue. May progress to colon cancer. Clinical findings: Patients complain of severe abdominal pain, fever, chills, anemia, and weight loss. Patient experiences profuse watery diarrhea of blood, mucus, and pus.

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UC vs Crohn’s

61 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Diverticulitis Diverticulitis is inflammation of diverticula, herniations through muscular wall in colon. Presence of fecal material through thin-walled diverticula causes inflammation and abscesses. Clinical findings: Patients complain of cramping pain in the lower left quadrant, nausea, vomiting, and altered bowel habits, usually constipation. Abdomen distended and tympanic; decreased bowel sounds and localized tenderness.

62 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.

63 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Viral Hepatitis Viral hepatitis: Inflammation of liver from viruses. Clinical findings: Common symptoms: Anorexia, vague abdominal pain, nausea, vomiting, malaise, and fever. Enlarged liver and spleen are classic findings. Liver inflammation may alter bilirubin conjugation so that patient’s sclera and skin are jaundiced, stools appear clay-colored, and urine is dark amber.

64 Cirrhosis Cirrhosis is chronic degenerative liver disease; causes include viral hepatitis, biliary obstruction, alcohol abuse. Clinical findings: Liver becomes palpable and hard. Associated signs: Ascites, jaundice, cutaneous spider angiomas, dark urine, clay-colored stools, and spleen enlargement. End-stage cirrhosis is hepatic encephalopathy and coma.

65 Cholecystitis Cholecystitis with cholelithiasis: Clinical findings:
Inflammation of gallbladder (cholecystitis); with gallstones (cholelithiasis) Bile duct becomes obstructed either by edema from inflammation or by gallstones. Clinical findings: Primary symptom is right upper quadrant colicky pain that may radiate to mid-torso or right scapula.* Indigestion and mild transient jaundice.

66 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Pancreatitis Pancreatitis is acute or chronic inflammation from autodigestion. Flow of pancreatic digestive enzymes into duodenum obstructed; digestive enzymes act on pancreas itself. Caused by alcoholism or by obstruction of sphincter of Oddi by gallstones. Clinical findings: Pain: Steady, boring, dull, or sharp; radiates from epigastrium to back. Patients prefer fetal position with knees to chest. Nausea and vomiting. Weight loss. Steatorrhea. Glucose intolerance

67 Urinary Tract Infection
Copyright © 2013 by Mosby, an imprint of Elsevier Inc. Urinary Tract Infection Urinary tract infections may involve urinary bladder (cystitis), urethra (urethritis), or renal pelvis (pyelonephritis). Most UTIs result from gram-negative organisms, such as Escherichia coli, Klebsiella, Proteus, or Pseudomonas, that originate from patient’s own intestinal tract and ascend through urethra to bladder. Clinical findings of UTIs: Symptoms of urethritis include frequency, urgency, and dysuria. Symptoms of cystitis include the above, plus signs of bacteriuria and perhaps fever. Patients with pyelonephritis complain of flank pain, dysuria, nocturia, and frequency.

68 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Nephrolithiasis Nephrolithiasis is formation of stones in kidney pelvis. Stones, or calculi, are made of calcium salts, uric acid, cystine, or struvite. Alkaline urine facilitates formation of stones made of calcium phosphate; acid urine facilitates stones formed of cystine. Clinical findings: Signs include fever and hematuria. A symptom is flank pain that may radiate to groin and genitals.

69 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Question 1 A nurse practitioner is performing a routine check-up on an adult male. As the nurse begins the abdominal assessment, the nurse knows to: Begin with observation of the patient’s general behavior. Begin with palpation if the patient is in pain. Ask the patient if he has noted any vascular sounds in the abdomen before. Ask the patient to straighten his legs for the abdominal exam. Correct Answer: A Rationale: Patients’ behaviors can offer clues to direct the rest of the exam. Are they grimacing? Are they guarding their abdomen? Is their gait smooth and symmetric? Inspection and auscultation should come before palpation. The knees/hips should be flexed for abdominal assessment. 69

70 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Question 2 When percussing the kidneys for tenderness, the nurse should: Start tapping at the level of T1. Tap in the costal angle. Use the direct or indirect method of percussion. Know whether the patient has a history of cholelithiasis. Correct Answer: C Rationale: The costovertebral angle is at the level of the twelfth rib, not at T1 (which is the base of the neck). The costal angle is over the stomach anteriorly. Cholelithiasis is not related. 70

71 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Case Study Sylvan is a 44-year-old male who works at the local grocery store. His four children live in his home with him. He has a history of hypertension and erectile dysfunction. He and his wife have been married for 14 years.

72 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Case Study (contd.) Subjective data: Complains of gas, belching, and food regurgitation after eating, especially spicy foods. This has existed for at least 2 months. Rolaids help, but his condition seems to be getting worse. Objective data: Vital signs: T 98.2; P 71; R 8. Height: 6’4”; Weight 300 lb. Lungs: Clear, no wheezing or rales present. Heart: RRR, no murmurs. GI: ABD: Soft + BS all four quadrants.

73 Copyright © 2013 by Mosby, an imprint of Elsevier Inc.
Case Study (contd.) Questions: What risk factors does Sylvan have for GERD? What measures might have helped prevent GERD? What should the nurse do in this clinical situation? Prioritize actions. Answers: Risk factors present for GERD are: Eating spicy foods Regurgitating food Being obese What measures might have helped to prevent GERD? Instruct patient on importance of losing weight. Instruct patient on importance of limiting spicy foods. Instruct family on importance of not eating and immediately going to bed. Appropriate actions in this situation are: Assess for patient and familial understanding of teaching. Suggest possible involvement of nutritionist. Assess for medicine compliance.


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