237 terms

nurs 1145

What is Nursing?
Nursing is promoting health, protecting, and caring for patients. It is prevention of illness and injury, alleviation of suffering through the diagnosis and treatment of human response, and advocacy in the care of individuals, families, communities, and populations.
What is a Scratch Test (GI) and how do you perform it?
- Helps to locate lower edge of liver

- Place stethoscope over RUQ above liver. With one finger of other hand, lightly scratch abdomen starting in RLQ moving up toward liver.

- When scratching sound heard thru stethoscope becomes magnified, you have reached liver border.
How do you percuss liver span?
- Right midclavicular line
- Below umbilicus, percuss upward (tympany to dullness)
- Over lung, percuss downward (resonance to dullness)
- Distance between two lines = liver span (2.5 inches/6-12 cm)
How do you test for Fluid Wave?
- Have the patient lying supine.
- The pt or an assistant places one or both hands (ulnar surface of hand downward) in a wedge-like position into the pt's mid abdomen, applying with slight pressure.
- Place the fingertips of one hand along one flank, and with the other hand firmly give a sharp tap along the opposite flank.
- Positive test: Nurse is able to detect "a shock wave" of fluid moving against the fingertips pressed along the flank, as the fluid is pushed from one side of the abdomen to the other by the force of the tap along the opposite flank.
How do you test for rebound tenderness (Blumberg's sign)?
- Palpate deeply and then quickly release pressure. If it hurts more when you release, the patient has rebound tenderness.

- Suspect appendicitis, peritonitis, or diverticulitis
How do you test for Murphy's sign and what does it detect?
- Used to detect inflamed gallbladder
- Stand at pt's right side, palpate at MCL at costal angle
- Pt takes deep breath, moving gallbladder closer to examiner's hand, causing pain on inspiration

- Presence of pain is positive Murphy's sign / Gall bladder disease
Iliopsoas muscle test
- Have pt lying supine
- use hand to apply pressure to lower thigh while pt attempts to flex hip
- Pain results from irritation of iliopsoas muscle

- Associated with peritoneal irritation / appendicitis
Obturator muscle test
- pt lying supine, flexes right leg at hip and knee
- Examiner places one hand just above pt's knee and other hand at ankle, rotate leg internally and externally
- Pain results from irritation of obdurate muscle

- suspect appendix / pelvic abscess
Palpation technique used to determine a floating mass
McBurney's sign
- press down on abdomen 2/3 from umbilical to iliac crest

- if pt feels pain when you relieve pressure suspect appendicitis
Abdominal distention may result from the 7 F's. What are the 7 F's?
Fat (Obesity)
Fetus (Pregnancy)
Fluid (Ascites)
Flatulence (Gas)
Feces (Constipation)
Fibroid Tumor
Fatal Tumor
Age-Related Variations for Older Adults
- increased regurgitation
- decreased gastric acids & digestive enzymes
- decreased absorption of vitamin B12 & fats
- reduced storage & protein synthesis in liver
What is common to see in aging adults?
Athersclerorsis, Arteriosclerosis
Calf-Vein Enlargement- Increased risk of DVT and PE
Skin and Hair changes- loss of hair on LE, thinner/shinier skin
Atrophy of lymphatic tissue
Loss of valvular competence
What is a normal heart beat for an adult?
60-100 beats per minute
What are the great vessels?
The pulmonary arteries and aorta
The portion of the body over the heart and lower chest.
The ares in which the heart lies. The middle section of the chest cavity.
Thick muscular tissue that contracts to eject blood from the ventricles.
What are the 4 heart valves?
- Tricuspid (right)
- Mitral (left)

- Pulmonic
- Aortic
Ventricles contract, creating pressure that closes the AV valves, preventing the backflow of blood into the atria. This pressure forces the Semilunar valves to open, resulting in ejection of blood into the aorta and pulmonary arteries. As blood is ejected, the ventricular pressure decreases causing the semilunar valves to close.
Ventricles are relaxed and fill with blood from the atria.
First heart sound
Closing of the mitral and tricuspid valves
Indicates the beginning of systole.
Low pitch
Almost always synchronized with the carotid pulse
2nd heart sound
Closing of the aortic and pulmonic.
Indicates the beginning of diastole
High pitch
Where is S1 heard the loudest?
The apex / lower left ventricle
Where is S2 the loudest?
The base / upper part of the heart
- common in young children
- caused by increased fluid / increased atrial pressure / extra blood flow

may indicate:
CHF / JVD / edema
mitral or tricuspid regurgitation

During diastole, often heard at the apex
- common in elderly
- Caused by hypertension / extra peripheral pressure

End of diastole
What is a murmur?
- dysfunctional valves
- can be from stenosis / regurgitation /or both
- some are intermitted
Systolic Murmur
A murmur occurring during the ventricular ejection phase of the cardiac cycle.
Caused by obstruction of the outflow of the Semilunar valves or by incompetent AV valves; structural deformities of the aorta or pulmonary arteries, anemia, and thyrotoxicosis
Diastolic Murmurs
A murmur occurring in the filling phase of the cardiac cycle.
Caused by: Incompetent semilunar valves or stenotic AV valves; dilation of the valvular rings
Indicates heart disease.
When a nurse finds a murmur, how should he/she document?
Pulse points
- temporal
- carotid
- apical
- brachial
- radial
- femoral
- popliteal
- posterior tibial
- dorsalis pedis
What is the pulse amplitude rating scale?
0+ Absent
1+ Diminshed, barely palpable
2+ Normal
3+ Full volume / bounding
4+ Full volume / increased
Valve does not open properly
Valve does not close properly
Palpable vibration over the precordium or artery: it feels like fine, palpable, rushing vibration. Associated with aortic valve stenosis
A more sustained thrust than an expected apical pulse and is felt during systole
More prominent thrust of the heart against the chest wall during systole.
- Amount of myocardial fiber stretch at the end of diastole
- Determined by left ventricular end-diastolic volume (LVED)
- Starling's Law
- Excessive filling= excessive LVED volume & pressure= decreased CO
- Pressure ventricles must overcome to eject blood into the peripheral blood vessels
- Amount of resistance is directly related to arterial B/P and the diameter of the blood vessels.
- Impedance: the pressure the heart must overcome to open the aortic valve; amount depends on compliance and total systemic vascular resistance.
Starling's Law
The more the heart is filled during diastole the more forcefully it contracts
Preload decreases/increases with?
- decreases with Diuretics

- increases with fluids
Sympathetic Nervous System
- Releases Norepinephrine
- Increases HR, AV conduction, Contractility
- Due to stress/anxiety
Parasympathetic System
- Release Acetylcholine
- Decreases Contractility, Conductivity, SA firing, and HR
- stimulates vagus nerve (by rectum or rubbing carotid artery)
Cardio subjective data
- Chest pain
- Dyspnea
- Orthopnea
- Cough
- Fatigue
- Cyanosis/pallor
- Edema
- Nocturia
- Cardiac history, Family cardiac history, Personal habits
Dyspnea becomes worse when lying down.
A person must stand or sit up to breathe easily.
The number of pillows necessary to relieve this problem.
Coughing up blood
Symptom of mitral stenosis
A brief lapse of consciousness.
When palpating the carotid artery, what should the nurse do?
Palpate one artery at a time. This stops the nurse from cutting off the oxygen and blood supply to the brain when palpating both carotids at the same time.
Hows does the nurse inspect the jugular vein for pulsations?
- Elevate the head of the bed to semi-fowlers position
- Use a penlight and observe for pulsations
- The vein itself should not be visible, only the pulsations
When taking blood pressure in both arms, what should you find?
A difference of 5-10mm Hg systolic between the 2 arms.
How long should it take for capillary refill? What does a greater time indicate?
- Less than 2 seconds

- Poor perfusion
Clubbing of nails
- chronic hypoxia
- common with cystic fibrosis or COPD
- Nail bed angle is greater than 180 degrees
a visible sinking in of tissues between and around the ribs.
Where do you palpate the apical apex of the heart?
The 5th intercostal space, left midclavicular line. This is the Point of Maximal Impulse.
Where do you auscultate for heart sounds?
1. Aortic Valve
2. Pulmonic Valve
3. Erb's Point
4. Tricuspid Valve
5. Mitral Valve
What happens when the mitral and tricuspid valves do not close at the same time
S1 sounds as if it were split into 2 sounds instead of 1.
Splitting is often heard?
Tricuspid area with deep inspiration
What is the 1st sign of Coronary Artery disease
Paroxysmal Nocturnal Dyspnea
Shortness of breath that awakens the individual in the middle of the night, usually in a panic with the feeling of suffocation.
How do you auscultate the carotid arteries for bruits?
With the bell of the stethoscope
Low-pitched blowing sounds usually heard during systole that indicate occlusion of the vessel.
How does the nurse estimate the jugular venous pressure?
- Identify the highest level at which jugular vein pulsations are visible, and then identify the angle of Louis.
- Use a ruler to create an imaginary line from the highest venous pulsation to the angle of Louis. Measure the vertical distance between the ruler and the angle of Louis.
- The pressure should not rise above 1 in (2.54cm) above the sternal angle
What does an EKG assess?
Rate and rhythm of the heart
How do you palpate the epitrochlear lymph nodes?
- Flex the client's arm to a 90 degree angle and palpate below the elbow posterior to the medial condyle of the humerus
- There should be no palpable lymph nodes
What are lymphatic ducts highly influenced by?
infection or cancer
Trandelenburg's Test
- Test competence of venous valves in patients with varicose veins
- Have pt lay in supine position, lift one leg above the level of the heart to allow veins to empty, then assist the client to stand.
- If veins are competent, veins fill slowly
- Fill too rapidly = valves may be incompentent, and varicose veins may be present.
What is the preferred position for cardiac palpation?
Allen's Test
- Important when drawing arterial blood
- Check to see if patient has good circulation through the ulnar artery. (Collateral circulation)
- Raise arm above patients head and hand in a fist for about 30 seconds. Pressure is put on the radial and ulnar arteries, then have the patient open fist, which should be pale. Ulnar pressure is released and color should return in 7 seconds.
- If color does not return in 7-10 seconds, the test is considered positive & the ulnar artery supply is not sufficient.
What are some immune related organs?
- Tonsils
- lymph nodes
- thymus gland
- spleen
- bone marrow
- No cure / lifetime of problems
- Swelling that generally occurs in one arm or leg but may be both
- Caused by a blockage in lymphatic system. The blockage prevents lymph fluid from draining well, and as the fluid builds up, the swelling continues.
What is the number 1 cause of preventable deaths in hospitalized patients?
Pulmonary Embolism
Venous Insufficiency
More pain when legs are dangling, blood pools - does not return
Arterial Insufficiency
Dependent rubor, no hair, shiny skin, thick toe nails, pale feet
Circulation: pallor, mottling (spotting), due to cold
Treatment: Increase O2
What is the Pitting Edema Scale?
1+ A barely perceptible pit, 2mm
2+ A deeper pit, rebounds in a few seconds, 4mm
3+ A deep pit, rebounds in 10-20 seconds, 6mm
4+ A deeper pit, rebounds in >30 seconds, 8mm
When assessing edema, what should the you do?
Push on bony prominences
Trace edema - push down then drag finger along
Deep Vein Thrombophlebitis
- a blood clot (thrombus) in one or more of the deep veins, usually in the legs
- Can cause leg pain, but often occurs without any symptoms.
- can happen from sitting for a long period of time
-can travel to lungs causing pulmonary emboli
- to prevent use stockings
- don't use stockings or massage legs if suspected DVT
Vascular Subjective Data
- leg pain or cramps
- swelling
- medications
- lymph node enlargement
- skin changes on arms or legs
Femoral Arteries
Between pubis and anterior superior iliac crest
Frog like position, press firm then release.
Popliteal Arteries
Lateral to medial tendon of knee
Curl hand around knee, press hard
Posterior Tibial (PT)
Groove between medial malleolus and achilles tendon
Curve fingers around medial malleolus
Dorsalis Pedis
Parallel with tendon of big toe
Light touch
Manual Compression Test
- Compress vein on lower leg
- Feel for wave: no wave- competent valves, wave felt- incompetent valves
Homan's Sign
- Supine with knee flexed
- Sharply flex foot toward tibia
- Pain indicates: DVT, Tendinitis, Muscle injury, lumbosacral problems
Raynaud's Syndrome
- Auto-immune disorder
- blood vessels in the hands and feet appear to overreact to cold temperatures or stress
Aterial Vascular Symptoms
- Claudication
- Pain with exercise or at rest
- Decrease or absent pulses
- Thin, shiny, hairless skin
- Cool skin temperature
- Ulcers on pressure points of feet
Venous Vascular Symptoms
-Pain increases when legs dependent
- Lower extremity edema
- Brown discoloration of skin
- Ankle Ulcerations-meaty
- Skin temperature normal
- Pulses present, but difficult to palpate due to edema
- Pain when dangling legs
What are the reference lines of the thoracic cage?
Midsternal Line
Midclavicular line
Scapular line
Vertebral Line
Anterior, posterior, & midaxillary lines.
Four functions of respiratory system
- changing chest size during respiration
- inspiration
- expiration
- control of respiration
Thorax and Lungs Subjective Data
• Cough (productive?)
• Shortness of breath
• Chest pain with breathing
• History of respiratory infections
• Smoking history (packs/years)
• Environmental exposure
• Self‐care behaviors (flu shot)
The posterior back is made up mostly of what lobes of the lungs?
The lower lobes
The process of moving gases in and out of the lungs by inspiration and expiration
The process by which oxygen and carbon dioxide move from areas of high concentration to areas of low concentration.
What regulatory agency has guidelines and regulations to reduce the amount of occupational exposure to respiratory irritants?
What are the primary muscles of inspiration?
The diaphragm and the intercostal muscles
What are the 3 functions of the upper airway in respiration?
- to conduct air to the lower airway
- to protect the lower airway from foreign matter
- to warm, filter, and humidify inspired air
When is a cough considered acute?
When its onset is sudden and it lasts less than 3 weeks
When is a cough considered chronic?
When it lasts longer than 3 weeks
What are common causes of acute cough?
- Viral infections
- allergic rhinitis
- acute asthma
- acute bacterial sinusitis
- environmental irritants
What are common causes of chronic cough?
- Postnasal drip
- asthma
- chronic bronchitis
- bronchiestasis
- cystic fibrosis
- chronic interstitial lung disease,
- smoking
- sarcoidosis
When assessing the timing of a cough, what should the nurse ask the patient?
- Continuous?
- Afternoon/evening? Night? Morning?
- 3 months per year for 2 years?
When assessing a dry v/s moist cough, what should the nurse ask the patient?
- Hacking?
- Barking?
- Dry / Moist?
- Congested?
White/Clear Sputum
Occurs with colds, viral infections, allergy or bronchitis
Yellow/Green Sputum
Occurs with bacterial or viral infections
Black Sputum
Occurs with smoke/dust inhalation
Rust-colored Sputum
Occurs with tuberculosis or pneumococcal pneumonia (blood)
Pink and Frothy Sputum
- Occurs with pulmonary edema
- blood & extra fluid
- usually too weak to cough
- from deep down
- comes out with tube insertion
Tripod position
-Leaning forward with the arms braced against the knees, against a chair, or against a bed.
- Suggests respiratory distress
Normal respiratory rate
What is a normal respiratory rate for an adult?
12-20 breaths per minute
Men use what kind of breathing?
Abdominal Breathing
Women use what kind of breathing?
Thoracic breathing
Respiratory rate more than 20 BPM
Respiratory rate less than 12 BPM
Increased rate and depth of respiration
Anteroposterior (AP) diameter of the chest should be approxiamately?
- Half the lateral diameter, or 1:2 ratio of AP to lateral diameter

- ribs should slope down at about 45 degrees relative to the spine
Barrel Chest
- Costal angle greater than 90 degrees
- Associated with COPD & pulmonary disease
Vocal fremitus
- Instruct patient to recite: one-two-three or 99 while the you systematically palpate the chest wall

- fremitus should feel bilaterally equal

- enhanced vibrations = lung tissue is congested or consolidated (pneumonia/tumor)

- decreased vibrations = blocked (emphysema, pleural effusion, pulmonary edema, or bronchial obstruction)
Breath sounds should be?
Clear to Auscultation (CTA)
What are the 3 normal types of breath sounds in the thorax?
Vesicular, bronchovesicular, bronchial
Where are bronchial breath sounds commonly heard?
- Over the trachea & immediately above manubrium

- expiration louder & longer than inspiration
- pause between
Where are bronchovesicular breath sounds normally heard?
- Main stem bronchi
- 1st and 2nd intercostal spaces at sternal border anteriorly; T4 medial scapula posteriorly

-louder inspiration & expiration
Where are vesicular breath sounds normally heard?
- Peripheral lung fields

- expiration is quieter than inspiration
- no pause between
What sounds should be heard over almost all of the posterior lung fields and all the lateral surfaces?
Vesicular breath sounds
When observing the patient's breathing, what should you note?
Breathing is smooth, even respiratory depth.
Chest wall should symmetrically rise and expand and relax without effort
Adventitious Breath sounds
Crackles, wheezes, and rhonci
Extraneous sounds that are superimposed on the breath sounds.
What should you do if you hear an adventitious breath sound?
- Identify the type of sound
- location of the sound (R/L lung, bilaterally; upper/lower lobes; anterior/posterior)
- phase of breathing in which it is heard
What causes crackles?
- sudden opening of very small airways
- extra fluid
- static sound
- could be congested heart failure
Fine crackles
- Fine, high-pitched crackling and popping noises (discontinuous sounds)
- Heard during the end of inspiration
- Not cleared by cough
Medium crackles
- Medium pitched
- moist sound heard about halfway through inspiration
- Not cleared by cough
Coarse Crackles
- Low-pitched, bubbling or gurgling sounds that start early in inspiration and extend into the first part of expiration
- High-pitched, musical sound similar to a squeak
- heard more commonly during expiration, but may also be heard during inspiration
- narrowing of airways
- could be asthma or congested heart failure
- Sonorous Wheeze
- Low-pitched, coarse, loud, low snoring or moaning tone
- Actually sounds like snoring
- Heard primarily during expiration, but may also be heard during inspiration
- Due to passage of air through a narrowed bronchus
Coughing may clear
Pleural Friction Rub
- superficial, low-pitched, coarse rubbing or grating sound
- Sounds like 2 surfaces rubbing together
- Heard throughout inspiration and expiration
- Loudest over the lower anterolateral surface
- Not cleared by cough
- Creaking noise
- Movement of visceral pleura over parietal pleura
- lung cancer
Respiratory Stridor
- Harsh, high-pitched sound associated with breathing that is often caused by laryngeal or tracheal obstruction
- Emergency Situation
- Croup, no lung sounds
- may be heard without stethoscope
- Usually louder in the neck than the chest
Atelectatic Crackles
- collapsed small alveoli
- cleared by cough or a couple deep breathes
What tests can the nurse perform to test for vocal resonance?
Bronchophony, Whispered Pectoriloquy, Egophony
- To assess vocal resonance
- Have pt repeat 99, listen with the diaphragm of the stethoscope, systematically auscultate the posterior thorax
- Listen to the response. The expected response is a muffled tone such as "nin-nin"
- Abnormal: if sound is louder and clearer (pneumonia)
Whispered Pectoriloquy
- Referred to as an exaggerated bronchophony
- Ask pt to whisper, "one-two-three"
- Systematically auscultate the posterior thorax, listening for the quality of the whispered tones
- Normal: response is muffled "1-2-3"
- Abnormal: Increased clarity and loudness of the sounds (consolidation or compression of the lung / pneumonia/fluid)
- Evaluates the intensity of the spoken voice
- Instruct the patient to say "e-e-e", as you auscultate the posterior thorax
- Normal: Expected sound if the muffled "e-e-e"
- Abnormal Findings: Changes in intensity and pitch, sounds more like and "a-a-a"
Biot Breathing pattern
Irregularly interspersed periods of apnea in a disorganized and irregular pattern, rate, or depth.
Intervals of apnea interspersed with a deep and rapid breathing pattern.
Air Trapping
Abnormal respiratory pattern frequently seen in clients with COPD
When palpating a patient, what should you observe?
Symmetric expansion of the chest
Tactile (vocal) fremitus
Palpate the entire chest wall
Diminished or absent breath sounds are common in patients with?
Emphysema, atelectasis, severe asthma attack
What techniques should the nurse use to auscultate the patient?
- Use the diaphragm of the stethoscope
- Mouth open
- Breathing deeply and fairly rapidly
- Systematic approach over several areas
comparing both sides
What are ways to measure pulmonary function status?
Forced expiratory time
Pulse oximeter (norm above 95%)
6 minute distance walk (300 meters)
Pectus carinatum
- Pigeon Chest
- Prominent Sternum
- either cosmetic or genetic diseases
Pectus excavatum
- Funnel chest
- The sternum is indented above the xiphoid process
- Congenital abnormality
- many cases just cosmetic
- Marfan's Syndrome
- Curvature of spine
- Prone to pneumonia on the smaller size
- Spinal convexity
- Half the body: ribs close together, other half ribs are widely separated
Pleural Effusion
- Reduced tactile vocal fremitus
- Reduced chest expansion
- Reduced airway
- Diminished BS
- Fluid within pleural space
- Increased tactile vocal fremitus
- Reduced expansion
- Dull perception
- Bronchial breathing
- Diminished BS
- Pneumonia
- Deviated trachea
- Reduced tactile vocal fremitus
- Hyper-resonance
- Reduced air entry
- Air in the pleural spaces; 3 different types: closed, open, and tension
- Deviated trachea
- Reduced tactile vocal fremitus
- Dull percussion
- Reduced air entry
- Poor air exchange
- Collapsed alveoli caused by external pressure from a tumor, fluid, or air in the pleural space or by removal of air from hypoventilation or obstruction by secretions.
- O2 levels may go below 90%.
- Diminished or absent breath sounds in affected lungs
- bed rest / immobility
- Infection of the terminal bronchioles and alveoli
- Caused by bacteria, fungi, viruses, mycoplasma, or aspiration of gastric secretions
- Important to get patients up after surgery to prevent this
When will you hear hyperresonance?
when there is overinflation of the lung
When percussing the posterior and lateral thorax, what sound should you hear?
The sound should be resononant, which is loud in intensity, low in pitch, long in duration, and hollow in quality
Diaphragmatic Excursion
- Movement of the diaphragm with maximum inspiration and expiration
- Allows the nurse to estimate the lower lung border during inspiration or expiration
What normal findings should the nurse see when measuring diaphragmatic excursion?
The diaphragmatic excursion should be equal bilaterally and measure at least 1-2 inches; in well conditioned individuals it may measure as much as 3 inches.
When palpating the trachea, what are normal findings?
- The trachea should be palpable, midline, and slightly movable

-abnormal: thorax mass / mediastinal shift / lung collapse / lung cancer / tracheal tumor
What are the normal/abnormal finding in palpating the anterior chest for thoracic expansion?
normal: thumbs should move apart symmetrically

abnormal: unequal movement can be the result from pain / fractured ribs / pneumonia / chest wall injury
Breast Subjective Data
- pain
- lump
- discharge
- rash
- swelling
- trauma
- breast reduction
- breast augmentation
Lump assessment
Use a circular, wedge, or vertical strip method to palpate for lumps throughout the breast, up to the chest, and through the tail of spence
If lump is present note....
- size
- location
- shape
- consistency
- mobility
- distinctness
- nipple retraction
- overlying skin
- tenderness
- lymphadenopathy (enlarged lymph)
What is the most common area of the breast for breast cancer?
Axillary tail of spence
What are the 4 quadrants the abdominal cavity is divided into?


- epigastric
- umbillical
- suprapubis
What are the nine regions of the abdomen?
Right hypochondriac/ Epigastric/ Left hypochondriac
Right lumbar/ Umbilical/ Left Lumbar
Right Inguinal/ Hypogastric/ Left Inguinal
What is the serous membrane that protects and lines the abdominal cavity?
The peritoneum
What are the 2 layers of the peritoneum?
The parietal peritoneum
The visceral peritoneum
Abdominal / GI Subjective Data
Food intolerance
Abdominal Pain
Bowel Habits
Abdominal History
What should you inspect the abdomen for?
Pulsations or surface movement
Hair distribution
Upon inspection of the abdomen, what should you find?
Smooth surface characteristics, striae/scars/faint vascular network. Umbilicus should be centrally located.
Contour of the abdomen should be flat or slightly sunken
Peristalsis should not be visible. Smooth and even respiration movements.
Peristalsis is under the control of what?
The Autonomic Nervous System
Pepsin breaks down?
Proteins- into peptones and amino acids
Gastric Lipase acts on?
Emulsified fats to convert triglycerides to fatty acids and glycerol
What is the largest organ in the body?
The liver
What part of the stethoscope do you use to auscultate the abdomen for Bowel sounds?
What are normal bowel sounds?
High-pitched gurgles or clicks
What may cause an absence of bowel sounds?
Mechanical obstruction or paralytic ileus
Perotonitis and bowel obstruction
How often should bowel sounds be noted?
Every 5-15 seconds
Abnormal bowel sounds
Hyperactive peristalsis; Vasular-burits; venous hums
Technique used to listen to bowel sounds
Auscultate in all four quadrants. Also can use percussion to hear tymphany and dullness
Ausculation of the abdomen should be done before?
Palpation or percussion
When does a nurse not palpate?
When the patient is suspected to have:
Enlarged spleen
Aortic Aneurysm
Reasons for dull sounds in the GI
liver, or distended bladder
Glistening or taut appearance of the abdomen caused by excessive fluid
Bulges during coughing indicates?
Abdominal hernia, ventral, umbilical, inguinal, or femoral.
True or False: The area of pulsations is not palpated because it may indicate an abdominal aneurysm, a weakening in the wall of the abdominal aorta.
How should the stoma appear on a patient with an ileostomy or colostomy?
Red and moist; the skin should appear well healed and without lesions, irritation, or areas of excoriation.
Clients with an ileostomy have stool that is?
Thick liquid in consistency
A patient with a transverse level colostomy, the stool is?
If the patient has an colostomy in the area of the descending or sigmoid colon, the stool is?
More solid
- Audible sounds produced hyperactive peristalsis
- Creates rumbling, gurgling, and high-pitched tinkling sounds.
- More intense and episodic sounds, associated with intestinal obstruction.
In what way should the nurse auscultate the abdomen?
Systematic way. Starting in the RUQ and progressing through clockwise.
What does CVA tenderness indicate?
Pyelonephritis, glomerulonephritis, or nephrolithiasis (kidney stones)
What 2 tests can the nurse perform if it is suspected that the patient has fluid within the abdomen?
Shifting dullness
Fluid Wave
Shifting Dullness
Ask the pt to lie supine so that any fluid pools in the lateral (flank) area. Percuss the abdomen. Draw lines on the abdomen to indicate the midline tympany in contrast to lateral dullness. Then have the client turn to the right side and repeat percussion. Listen as the tympanic tone shifts to the upper side and the area of dullness rises toward the midline. FInally, have the client turn to the left lateral position and percuss. Listen as the dullness rises toward the midline. (+) Movement of dullness
What are the 4 different types of abdominal contours?
Hypoactive Bowel Sounds
Reduced bowel sounds.
reduction in the loudness, tone, or regularity of the sounds. They are a sign that intestinal activity has slowed.
Normal during sleep, and also occur normally for a short time after the use of certain medications and after abdominal surgery. Decreased or absent bowel sounds often indicate constipation.
Hyperactive Bowel Sounds
Increase in intestinal activity.
Can occur with diarrhea, Crohn's disease, GI bleeding, ulcerative colitis
When percussing the abdomen what are the normal sounds heard?
Tympany (Bowels)
Dull (Liver)
Flat (Bone)
When is the suprapubic area sound dull?
When the urinary bladder is distended.
Light palpation is used for?
Tenderness, muscle tone, and surface characteristics
(1-2 cm)
Deep palpation is used for?
Tenderness, masses, and aortic pulsation
(4-6 cm)
Patterns of bowel and urinary elmination, problems with control, and use of assistive devices; also explores skin excretion
What are the 9 Ways to gain more information?
Previous history
Data documented for use by health care team needs to be:
- Complete, accurate,descriptive data.
- Concisely, legibly, and without bias or opinion.
What are the four assessment techniques?
Inspection, Palpation, Percusion, Auscultation
The act of listening to sounds w/in the body.
A visual examination of the body, including body movement and posture.
Using the hands to feel texture, size, shape, consistency, pulsations, and location of certain parts of the body.
Used to evaluate the size, borders, and consistency of internal organs, to detect tenderness, and to determine the extent of fluid in a body cavity.
Pulse Oximetry purpose
To estimate the arterial oxygen saturation in the blood
Measures for far vision. A chart that is held 20 ft from the client.
Measures near vision; Chart made up of 3's, X's, and O's; Held 14 inches from client's face
Reflex hammer
To test deep tendon reflexes; Strike directly
Tuning fork
Auditory screening and assessment of vibratory sensation
Range for auditory screening
500 to 100 Hz
Range for assessment of vibratory sensation
100 to 400 Hz
Used to determine the degree of flexion or extension
test for sensation on lower extremities
Used to amplify sounds that are difficult to hear with an acoustic stethoscope. Uses ultrasonic waves to detect difficult to hear vascular sounds.
Location of prostate
Beneath the urinary bladder; palpable through the rectum
Internal Hemorrhoids
May not be seen unless thrombosed, prolapsed, or infected
External Hemorrhoids
Flaps of tissue; Itching, blue or purple
Rectal prolaspe
A full thickness prorusion of the rectal wall through the anus; most women >60 yo
Where is the kidney percussed?
The costovertebral angle
Costal angle meaning
Unilateral or unequal mvmt of expansion suggests asymmetry. This is related to pneumonia, atelectasis, or collapsed lung
An enlarge liver can be associated with?
Cirrhosis or high cholesterol
What are the 8 functions of the liver?
- Bile production and secretion
- Transfer of bilirubin from the blood to the gallbladder
- Protein, carbohydrate, and fat metabolism
- Glucose storage in the form of glycogen
- Production of clotting factors and fibrinogen
- Synthesis of most plasma proteins
- Detoxification of a variety of substances, including drugs and alcohol
- Storage of certain minerals (iron and copper) and vitamin (A, B12, and other B-complex vitamins)
What are the main functions of the spleen?
- Storage of 1-2% of erythrocytes and platelets
- Removal of old or agglutinated erythrocytes and platelets
- Activation of B and T lymphocytes
- Production of erythrocytes during bone marrow depression
What are the five percussion tones?
1) Typany - loud, high pitched sound heard over abdomen
2) Resonance - heard over normal lung tissue
3) Hyperresonance - heard in overinflated lungs, as in emphysema
4) Dullness - heard over liver or heart
5) Flatness - heard over bones and muscle
What is an apical impulse?
A brief, early systolic outward thrust, followed by a late systolic retraction felt by the palpating finger when the LV contracts and rotates the LV apex and the adjacent interventricular septum hits against the chest wall.
What mechanism produces normal S1 & S2 heart sounds?
Isovolumetric Ventricular Contraction
What are risk factors for venous stasis?
- age
- being female
- being tall
- genetic factors
- obesity
- pregnancy
- prolonged sitting or standing