310 Abdominal Validation

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Term
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Tools needed
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Terms in this set (25)
Tools needed
Stethoscope, Percussion hammer
Pre-Assessment
- patient empty bladder
- place patient supine with pillow behind head and hands at side
- NURSE ON RIGHT SIDE
Identify and describe four quadrants + nine regions
Image: Identify and describe four quadrants + nine regions
Order of Assessment
inspection, auscultation, percussion, palpation
Inspect what
skin tone and appearance, scars and striae, rashes/lesions/masses, skin turgor, peristalsis and pulsations, shape and contour, umbilicus
Inspect skin tone and appearance
skin should be smooth, dry, and even with homogenous color
Inspect scars and striae
size, appearance, location
Inspect rashes, lesions, and masses
refer to skin assessment (ABCDE)
Asymmetry
Border
Color
Diameter
Elevation
Inspect skin turgor
reflects hydration
- pinch up fold of skin and release
expected: immediate return of skin to original position
unexpected: tenting
Inspect peristalsis and pulsations
squat @ eye level and look across patient's abdomen
- peristalsis wave may be visible in thin individuals
- normal aortic pulse frequently visible in epigastric region
Inspect shape and contourcontour describes nutritional state, squat @ eye level to assess Flat: appropriate weight and muscle tone Scaphoid: sunken (dehydration), normal in thin frame Rounded: slightly overweight, rolls of subcu fat present along sides Protuberant: markedly distended (pregnancy, obesity, ascites, tumors)Inspect umbilicusnote contour, location, signs of inflammation or herniaAuscultate whatBEGIN in RLQ + clockwise bowel sounds, venous hum, friction rubs, bruitsAuscultate bowel soundsActive: normal, high pitched, occur 5-15 seconds (5-30/min) Hyperactive: louder and more intense, signify increased motility, occur about every 3 seconds (more than 30/min) Hypoactive: diminished and soft, signify impaired motility, occur less than 5 per minute Borborygmus: hyperactive bowel sounds that are heard without stethoscope, stomach growling Absence: indicate bowel obstruction, must listen for 5 minutes and have a second nurse verify findingsAuscultate venous humA continuous medium pitches sound, auscultated in epigastric and umbilical regionAuscultate friction rubsAuscultate liver (RUQ) and spleen (LUQ) for presence of friction rubs, abnormal rough grating soundAuscultate bruitsuse bell of stethoscope over abdominal aorta, renal arteries, iliac arteries, and femoral arteries - indicates turbulent blood flowPercuss whatTympany/dullness + Stomach gastric air bubble - RLQ clockwisePercuss tympany/dullnessNote changing sounds, tympany should predominate because air rises when patient is supinePercuss stomachpercuss area of stomach under ribcage -expected: sound is tympanic over gastric air bubble located at left 6th-7th ribPalpate whatlight palpation, deep palpation, aorta - ask patient if ab pain is present before beginning, palpate painful area lastPalpate light palpationuse palmar surface of fingertips to depress lightly over entire abdomen to assess for - Superficial pain, organs, masses - Muscular resistance (muscle tone) - Abdominal tenderness + involuntary rigidity (constant, board like hardness and ab muscles)Palpate deep palpationuse more pressure than light palpation, palpate for -distinguishing inferior organs or elicit deep pain -deep masses (if discovered note size, location, mobility (including w respiration) contour, consistency, and tendernessPalpate aortic pulsationpress into upper abdomen slightly left of midline - identify aortic pulsation expected: 2-4 cm wide and pulses anteriorly unexpected: prominent pulsation w lateral expansion = aortic aneurysmAssess superficial reflexes of abdomenUpper abdominal reflexes: stroke abdomen towards umbilicus with handle of reflex hammer, umbilicus should move towards stimulus Lower abdominal reflexes: stroke abdomen below umbilical area but towards midline, umbilicus should deviate towards stimulus