Presentation on theme: "D. Tanner, RN, MSN NUR 211 Fall Semester"— Presentation transcript:
1 D. Tanner, RN, MSN NUR 211 Fall Semester Abdomen AssessmentD. Tanner, RN, MSNNUR 211Fall Semester
2 Anatomy of the Abdomen 4 Quadrants RUQ, RLQ, LUQ, LLQ Midline 9 Regions- epigastric, umbilical, suprapubicThe word "abdomen" has a curious story behind it. It comes from the Latin "abdodere", to hide. The idea was that whatever was eaten was hidden in the abdomen.
7 Location! Location! Location! RLQcecumappendixright ovary and tube
8 Location! Location! Location! LLQsigmoid colonleft ovary and tubeLUQstomachspleenpancreasleft kidney and adrenal
9 GI Variations Due to Age Aging- should not affect GI function unless associated with a disease processDecreased: salivation, sense of taste, gastric acid secretion, esophageal emptying, liver size, bacterial floraIncreased: constipation!
10 GI Variations with pregnancy Decrease in gastric motilityHigh incidence of N, V (r/t pregnancy hormones) and “heartburn” or acid refluxBowel sounds diminished r/t enlarged uterus displacing intestinesLinea nigra- increased pigmentation of abd midlineStriae Gravidarum
11 Nursing History - Abdomen Subjective Data:Ask about:AppetiteWt gain or lossDysphagiaIntolerance to certain foodsAny Abdominal Pain of Nausea and VomitingBowel movementsAny past abdominal problems
12 Nursing History Infants and Children – Ask: bottle or breast fed, any table foods, how often & how well & how much the baby eat, any problems with constipation, c/o of any abdominal painTeenagers-Ask: nutritional assessment, activity & exercise patterns, recent wt. loss or gain
13 Nursing History Older Adults Ask: how do you get your groceries? prepare your meals?do you have any trouble swallowing?how often do your bowels move?how often do you take anything for constipation? Rx / OTC/ herbswhat meds do you take?
15 Focused Health History NutritionAllergiesMedicationsCigarette/tobaccoETOH intakeRecreational drug useStool characteristicsUrine characteristicsExposure to infectious dz.Recent stressful life eventsPossibility of Pregnancy
16 Techniques for Exam Provide privacy Good lighting/appropriate temp in rmExpose the abdomenEmpty bladderPosition pt supine, arms by side & head on pillow with knees slightly bent or on a pillowWarm stethoscope & handsPainful areas lastDistraction techniques
17 Inspection Overall observation Abd contour- flat, scaphoid, round, protuberantAbd symmetry and skin color - note any masses, striae, scars, veins, pigmentationPulsations
18 Auscultation Always done before percussion & palpation Use diaphragm of stethoscopeListen lightlyStart with RLQ
19 Auscultation What makes a bowel sound? Note character & frequency of bowel sounds (5-30 times/minute)Sounds like…..Listen for 5 minutes before documenting absent bowel soundsListen for bruits- aortic, renal, iliac, femoralHyper- gastroenteritis, obstruction, hungryHypo- pregnancy, peritonitis
20 Percussion Gently tapping on the skin to create a vibration Detect fluid, gaseous distention and massesTympany- gas (dominant sound because of air in sm intestine)Dullness- solid masses, distended bladderPercuss liver, spleen ,kidneys
21 Palpation of AbdomenLight palpation- depress about 1 cm. Assess skin pulsations. Always done first- clockwiseDeep palpation- depress skin about 5-8 cm.Always assess tender areas last.Watch pt’s expression during palpation
22 Inspection Abnormal Findings Visible or distended veins- ascitesVisible peristalsis- obstructionSpider nevi (cutaneous angiomas)- cirrhosisAsymmetry/ Distention- mass or intestinal obsructionColor changes- jaundice, bluish/cyanotic
23 Abnormal Auscultation Absence/Hyperactive bowel sounds- “borborygmi”Bruits- “swoosh”Peritoneal Friction Rub- rough, grating heard over liver & spleen- inflammation of peritoneal surface from tumor, infection, etc.
25 Palpation Abnormal Findings Tenderness- rebound- done away from painful area- done at end of examMasses- document location, size, shape, mobile, pulsating, smooth, nodular, firmFirmness or muscle guarding/rigidity- intraabdominal bleeding- DO NOT CONTINUE TO PALPATE!!!!!!
26 Special ProceduresFluid Wave- need 3 hands- feel for impulse of the wave of fluid across the abdomen= ascitesRebound Tenderness- Blumberg’s SignIliopsoas Muscle Test- thigh muscle lift R leg and push down on R thigh= appendicitisObturator Test- lift R leg and rotate at 90 degrees= muscle is irritated by appendicitisMurphy’s Sign- “inspiratory arrest” palpate the liver should be painless= cholecystitis
27 Special Procedures McBurney’s Point- RLQ midclavicular= appendicitis Referred pain- location of pain is not necessarily where the involved organ is! May be felt where the organ was located in fetal development ex: spleen= L shoulder pain/ kidney= groin painHooking technique- palpate the liver- feeling for the liver edge
28 Special ProceduresCullen’s Sign- bluish discoloration around the umbilicus EMERGENCY!!!Kehr’s Sign- abd pain radiating to R shoulder= spleen or pancreatitis
29 Sample Documentation Normal Exam- Abdomen soft, rounded and symmetric without distention; no lesions or scars, or visible peristalsis. Aorta midline without bruit or visible pulsation; umbilicus inverted and midline without herniation; bowel sounds present in all 4 quadrants. Liver, kidney and spleen non-palpable; no tenderness on palpation. Reports good appetite; no constipation, nausea or diarrhea. Voiding well and denies laxative use.