abdominal assessment 2
Terms
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- a newborn's liver is located
- above the symphysys pubis
- because the abdominal muscles are weak of an infant, the abdomen usually protrudes
- protrudes
- bowel sounds are _____ in pregnant client
- diminished
- During pregnancy, the appendix, in the pregnant wm is displaced
- upward and laterally to the right
- visceral pain
- results from distention of the intestines or strecthing of solid organs. often discribed as burning, cramping, difuse, and poorly localized.
- results from distention of the intestines or strecthing of solid organs. often discribed as burning, cramping, difuse, and poorly localized.
- visceral pain
- parietal pain
- results from inflammation of the parietal perioneum, pain usually described as severe, localized and aggravated by movement
- results from inflammation of the parietal perioneum, pain usually described as severe, localized and aggravated by movement
- parietal pain
- referred pain
- felt at site away from site of origin. impulsed from internal organs and structures that share nerve pathways inside the cns explain nature.
- felt at site away from site of origin. impulsed from internal organs and structures that share nerve pathways inside the cns explain nature.
- referred pain
- order or symptom assessment
- RTQSP
- black tarry stool indicates
- upper gi bleed
- red bloody stool indicates
- lower gi bleeding
- clay colored stool indicates
- increased bile in obstructive jaudice
- indigestion is also called
- dyspepsia or pyrosis
- four quadrant method
- one line at midline and other horizontal at unblicas
- 9 regions of abdomen
-
1st 2 lines vertical at right and left mc line to midle of inguinal ligaments
2nd 2 lines horizontal beginning at lower edge of costal margin and at the anterosuperior iliac spine of the iliac bones - before doing abdominal exam have pt 1st
- empty bladder
- sequence for physical assessment
- inspection, auscultation, percussion, palpation. need to auscultation b4 percussion, palpation b/c may increas bowel sounds
- how do you accentuate a hernia
- lift head while lying in supine postion
- in normal adult contour of stomach should be either _____,_____, or _____ not _____
- flat, round, or scaphoid, not protuberant
- use diaprham to listen to _____
- bowel sounds
- when listening to bowel sounds there will be _____to_____clicks per minute, or bs occur every _____to_____ minutes on average adult.
- when listening to bowel sounds there will be 5 to 30 clicks per minute, or bs occur every 5 to 15 minutes on average adult.
- if bowel sounds are hypoactive liksten over
- the ileocecal valve, to the right of umblicus
- listen for vascular sounds with _____ of sthethescope
- bell
- _____ is the most common finding and indicates presence of gas
- tymphany
- place stethescope over RUQ above the liver, and with one finger of hand lightly scratch abdomen starting in RLQ and move upward toward liver. when scracthing sound in stethescope becomes magnified you reached liver border
- scratch test
- liver span test
- pg 499
- normal liver span at mc line is _____to_____cm
- 6 to 12
- normal liver span at midsternal line is _____to_____cm
- 4 to 8 cm
- if you hear _____ when percussing spleen, splenomegaly is unlikely
- tymphany
- with splenomegaly tymphany turns into _____ on inspriation
- dullness
- _____or _____ percussion can be used to access kidney for tenderness
- fist or blunt
- do not palpate abdomen is pt
- has had orgam transplant or suspected of wilm's tumor
- bladder usually not palpable unless_____. if palpable should feel like _____, _____ mass
- distended with urine. if palpable should feel like smooth, round mass
- ascites
- accumlation of fluid in perionteal cavity and usually detectable when 500 ml of fluid has accumulated
- three ways to test for ascites
- shifting dullness, fluid wave, and puddle sign
- when doing shifting dullness test if client has ascites
- you will hear dullness laterally and tymphany near the umbilical area
- fluid wave
- pg 509
- puddle sign
- pg 509
- upper abdominal reflexes assess if _____ thru _____ and are obtained by using _____ or _____
- upper abdominal reflexes assess if T8 thru T10 and are obtained by using end of reflex hammer or tongue blade and storking up and toward umbilicus
- lower abdominal reflexes assess if _____ thru _____ and are obtained by _____
- lower abdominal reflexes assess if T10 thru T12 and are obtained by Stroking downward and toward umbilicus
- normal response for abdimal reflexes is
- movement of umbilicus toward stimulation
- kehr's sign
- referred pain or hyperesthesia to left shoulder pg 509
- ballance's sign
- presnet when dullness is percussed IN THE LUQ. indicates periotoneal irritation or injury to the spleen
- murphy's sign
- used to detect inflammed gallbladder pg 509-511
- abdominal reflexes may be diminished in
- obese clients or those who may be pregnant
- abdominal reflexes may be absent in
- eldery
- where is mcburney's point
- 1/3 of the distance from anterior iliac crest to the umbilicus
- obturator muscle test
- helps diagnose ruptured appendix or pelvic abscess. pain should not occur in hypogastric region
- rovsing's sign
- assess peritoneal inflammation cause by appendicitis. place hand in LLQ and press deeply for 5 seconds. pain should not occur
- cutaneous hypersensitivity
- grasp fold of skin or touch abdominal suface with saftety pin to access for pain. do entire ab suface and pain shouldnt occur
- iliopsaoas muclse test
- pg 512
- rebound test
- pg 513
- name tests that access for appendictis [6]
- mcburney's sign, 0bduartor muscle test, rosing's sign, cutaneuos hypersensitvity, ilipsoas muscle test, rebound tenderness