Nursing 3080 Exam 2(weeks 6,7, 9,10,11, and 12)
Terms in this set (71)
what is the technique for an abdominal assessment?
dorsal recumbent with pillow supporting knees, flat HOB, raise bed to your level, also go to feet to check for symmetry of body
during abdominal assessment inspection, what should patient position be?
in abdominal assessment, what area do you inspect last?
right lower, clockwise
in abdominal assessment, typically start in what quadrant and go in which direction?
1. coloration of skin
2. abdominal contour
3. abdominal symmetry
4. scars and striae
6. lesions and ecchymosis
7. venous patterning
8. drains, tubes, stoma
abdominal assessment- what you look for during inspection
flat, rounded, or scaphoid
abdominal assessment- normal finding for abdomen inspection
when patient lost a lot of weight
abdomen assessment- yellow hue apparent on abdomen
abdomen assessment- significant abdominal swelling- fluid accumulation in abdominal cavity
1. nonhealing scar
4. deep, irregular scars
abdomen assessment- abnormal finding about scars
abdomen assessment- excess scar tissue resulting from trauma or surgery, overgrowth of tissue
-pregnancy and weight gain
abdomen assessment- describe normal striae
grey turner sign
abdomen assessment- purplish discoloration at flank that indicates bleeding within abdominal wall. due to trauma to kidney, pancreas, duodenum, or pancreatitis.
abdomen assessment- bluish or purplish discoloration around umbilicus, indicates intra abdominal bleeding
6 causes of abdominal distention
1. intermittent, soft clicks and gurgles should be heard at a rate of 5-30 per minute.
normal abdominal sounds
-hypoactive bowel sounds due to abdominal surgery or late bowel obstruction
-hyperactive bowel sounds due to inc. bowel motility- diarrhea, early bowel obstruction, gastroenteritis
abdominal auscultation- abnormal findings
absence of bowel mobility- emergency. causes are peritonitis or paralytic ileum. always stand and listen fro 5 minutes before calling someone
decreased or absent bowel sounds signify what?
abdominal assessment- what may bruits indicate
-begin in non tender quadrant
-compress to depth of 1 cm in dipping motion
describe process of abdominal palpation
abdominal palpation- what are normal findings
-tenderness or pain due to trauma peritonitis, infection, tumors, enlarged or diseased organs
abdominal palpation- abnormal findings
4. sigmoid colon
abdominal palpation- normal tenderness is possible over what 5 organs?
-begin at symphysis pubis
-move upward and outward to estimate bladder borders
describe palpation of bladder
-assess for tenderness
why do you percuss abdomen?
-blunt percussion of kidney
describe abdomen percussion
-place left hand flat against lower right rib cage
-use ulnar side of right fist o strike against left hand
-perform over 12th rib
how do you percuss abdomen?
abdomen percussion- what would tenderness or sharp pain possibly indicate?
-palpate deeply in abdomen where client has pain and suddenly release pressure
-listen and watch expression of pain
-ask client to describe which hurt more= pressing in or releasing
how to test for appendicitis(rebound tenderness)
-positive rebound tenderness
-occurs where client has sharp, stabbing pain as examiner releases pressure
-more pain occurs when pressure is released
describe Blumberg's sign
peritoneal irritation from appendicitis
why could Blumberg's sign occur?
1. Rovsing's sign
2. Blumberg's sign
3. Psoas sign
4. Obturator sign
four tests for appendicitis
-Palpate deeply in the LLQ and quickly release pressure
-normal- No rebound pain should be elicited
describe how to test the Rovsing sign
- Referred Rebound Tenderness- Pain in the RLQ during pressure in the LLQ
abnormal Rovsing sign findings
-Raise the client's right leg from the hip and place your hand on the lower thigh
-Ask client to try to keep the leg elevated as you apply pressure downward against lower thigh
describe how to assess for Psoas sign
-Support the client's right knee and ankle
-Flex the hip and knee and rotate the leg internally and externally
describe Obturator sign test
what is the test for ascites?
-Ask client to assist by placing the ulnar side of the hand and the lateral side of forearm along the midline of the abdomen
-Firmly place the palmar surface of your fingers and hand against one side of the clients abdomen
-Use your other hand to tap the opposite side of the abdominal wall
describe fluid wave test
-no fluid wave transmitted
what is normal findings for fluid wave test?
-Assess RUQ pain or tenderness
-tests inflammation of the gallbladder
-Press your fingertips under the liver border at the right costal margin ask the client to inhale deeply
describe test for cholecystitis(gallbladder)
what does Murphy's sign test for?
Accentuated sharp pain that causes the client to hold his or her breath
describe positive Murphy's sign
-use 24 hour urine test
-a metabolic disorder caused by overproduction of corticosteroid hormones by the adrenal cortex and often involving obesity and high blood pressure.
-harsh or hollow
-loud, short during inspiration
-long in expiration
normal lung breath sounds for bronchial
location of bronchial
normal lung breath sounds for bronchovesicular
location of bronchovesicular
-long duration in inspiration
-short in expiration
normal lung sounds for vesicular
LOCATION OF VESICULAR
high-pitched, short, popping sounds heard during inspiration and not cleared with coughing, sounds like rolling strand of hair
low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration, Velcro
high-pitched, musical sounds heard primarily during expiration but may also be heard on inspiration. ASTHMA or ALLERGIC REACTION
also called rhonchi, low-pitched snoring or moaning sound heard primarily during expiration but may be heard throughout the respiratory cycle. These may clear with cough.
pleural friction rub
low-pitched, dry, grating sound, much like crackles, only more superficial and occurring during both inspiration and expiration
Client leans forward and uses arms to support weight and lift chest to increase breathing capacity, referred to as tripod position
abnormal finding in COPD
-Ruddy to purple complexion may be see in clients with COPD or CHF
abnormal color of face, lips, or chest could indicate what
-While client sits with arms at sides, stand behind and observe the position of scalpula and shape and configuration of chest wall
Scalpulae should be symmetrical and non protruding
describe how to inspect chest wall and what is normal
trapezius, or shoulder, muscles are used to facilitate inspiration in cases of acute and chronic airway obstruction or atelectasis
abnormal findings in accessory muscles
what is nasal flaring indicative of?
asthma, emphysema, or CHF
what is pursed lip breathing indicative of?
greater than 20/min respirations and due to fear, anxiety, exercise
less than12/min and Normal or pneumonia, pleurisy
-increased rate & increases depth
-due to Fear, anxiety, *kaussmaul's respirations- associated with diabetic ketoacidosis
-decreased rate, decreased depth, irregular pattern
-Overdose of narcotics or anesthesia
--regular pattern characterized by alternating periods of deep, rapid breathing followed by periods of apnea
-Severe CHF, drug overdose, renal failure, increased ICP
-Spinous processes that deviate laterally in the thoracic area may indicate scoliosis
-Ribs appearing horizontal at an angle greater that 45 degrees with the spinal column are frequently the result of an increased anteroposterior-transverse diameter (barrel chest due to emphysema due to hyperinflation of lungs)
abnormal findings of spine and ribs
-pain- inflamed fibrous CT
-tenderness- inflamed fibrous CT
-not equal temperature
-pain over ribs- fracture
-Pain over the intercostal spaces may be from inflamed pleurae
-lesions and masses
abnormal findings for palpating anterior and posterior thorax
-placing your hands on client's anterolateral wall with thumbs also costal margins and pointing toward xiphoid process
-As client takes a deep breath, observe the movement of your thumbs
-Thumbs move outward in a symmetrical fashion from the midline
how to palpate chest expansion
-Place hands on the posterior chest wall with thumbs at level of T9 or T10 and press together small skin fold
-Ask client to take a deep breath, observe movement of thumbs
-When client takes a breath, the examiner's thumbs should move 5-10 cm apart symmetrically
how to a assess chest expansion
lungs- is dullness normal?
-Do not listen through drape or clothing
-Place diaphragm of stethoscope firmly and directly on anterior chest wall
-Ask client to breath deeply through his or her mouth
-Be alert to clients comfort and offer rest and normal breathing if fatigue occurs
describe how to auscultate anterior thorax