Question | Answer |
Prior to an abdominal assessment, what should you have your client do | empty their bladder, lay flat with knees slightly flexed and take slow deep breaths to promote relaxation before exam |
Sequence of assessment for the abdomen | Inspect, Auscultate, Percuss, Palpate |
purple discoloration at the flanks indicate | bleeding within the abdominal wall |
Pale, taut skin may be seen with | ascites (fluid accumulation in the abdominal cavity) usually results from liver failure or liver disease |
Dilated veins may be seen with | cirrhosis of the liver, obstruction of the inferior vena cava, portal hypertension or ascites |
normal findings of Striae (stretch marks) | old, silvery, white straie. bluish-pink striae are associated with cushing syndrome. |
Bluish or purple discoloration around umbilicus indicates | intra-abdominal bleeding |
A deviated umbilicus may be caused by | pressure from a mass, enlarged organ, hernia, fluid or scar tissue |
Keloids are more common in | African Americans and Asians |
Abdominal contours | Flat (-)
Scaphoid- (u)
Rounded- (n)
Distended/protuberant (d) |
A bulging in the abdominal wall may indicate | hernia |
The patient head is slightly lifted while assessing the abdomen this helps identify | masses |
Vigorous, wide spread pulsation may been seen with | abdominal aortic aneurysm (slight pulsation is normal) |
With intestinal obstruction, peristaltic waves are incrased and progress in a rippled-like fashion from the ___ to the ___. | Left upper quadrant (LUQ) to the right lower quadrant (RLQ) |
What is the rate of normal bowel sounds. | 5-30 bowel sounds per minute. (intermittent, soft clicks and gurgles) |
Hypoactive bowel sounds indicate..
Hyperactive bowel sounds indicate..
Decreased or absent bowel sounds indicate.. | Hyperactive-diarrhea, gastroenteritis or early bowel obstruction
Hypoactive- diminished bowel motility and caused by abdominal surgery or late bowel obstruction
Absent or decreased- requires emergency referral |
When a bruit is heard over the abdominal aorta? | aneurysm or arterial stenosis |
Generalized tympany(high pitched) is usually heard over the abdomen because | of air in the stomach and intestines |
Hepatomegaly is | when the liver span exceeds normal limits (enlarged) is characteristic of liver tumors, cirrhosis, abscess, or vascular engorgement |
The normal liver span at the MSL (mid-sternal line) is | 4-8 cm |
Light palpation depth | 1 cm |
Deep palpation depth | 5-6 cm |
The spleen is normally palpable, if the spleen is palpable this may indicate | chronic blood disorder, cancer, mononucleosis |
Blumberg's sign is | when the client has rebound tenderness when he or she perceives sharp, stabbing pain as the examiner releases pressure form the abdomen |
Pain in the RLQ during pressure in the LLQ is a positive _____ sign. | Rovsing's It suggests acute appendicitis |
Polyuria | Increased frequency of urine |
Oliguria | Decreased frequency of urine |
Anuria | Without urine |
Nocturia | Getting up in the middle of the night to use to the bathroom (frequent) |
Dysuria | Painful urination |
Incontinence | Cant go to the bathroom |
Character of abdominal pain & implications | Dull & achy
Burning, gnawing
pressure
Colicky (permanent, tight muscles)
sharp, knifelike |
Referred pain | Travels or refers from the primary site and becomes highly localized at the distant site. Example: right neck pain-gallbladder, left shoulder pain-pancreas or spleen |
Risk factors for gallbladder | women, obesity, smoking, diet |