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RN Nursing > HAPS abdomen assessment > Flashcards

HAPS abdomen assessment Flashcards

1
Q

subjective data with abd assessment

A 
appetite
dysphagia
food intolerance
abd pain
n/v
bowel habits
past abd Hx
medications
nutritional assessment
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2
Q

Sister Mary Joseph nodule

A

hard nodule i umbilicus that occurs with metastatic cancer of the stomach, large intestine, ovary, or pancreas

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3
Q

Cullen sign

A

bluish periumbilical color occurs (though rarely) with intraperitoneal bleeding

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4
Q

lineae albicantes

A
  • aka striae
  • silvery white, linear, jagged marks about1-6 cm long
    occur when elastic fibers in the reticular layer of the skin are broken after rapid or prolonged stretching as in pregnancy or excessive wt gain
  • recent striae are pink or blue, then turn silvery white
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5
Q

borborygmus

A

hyperperistalsis

stomach growling

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6
Q

vascular sounds

  • what is it
  • how to listen
A

aka bruits

pulsatile blowing sound and occurs when stenosis or occlusion of an artery

use firmer pressure, check over aorta, renal arteries, iliac, and femoral arteries

usually no sound is present

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7
Q

pH of stomach
vs
pH of intestines

A

1-4 stomach

6-9 intestine

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8
Q

when is dullness heard in abd

A

occurs over a distended bladder, adipose tissue, fluid, mass

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9
Q

hyperresonance in abd occurs when:

A

gaseous distention

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10
Q

how to find liver span

A

find MCL
begin in area of lung resonance
percuss down the interspaces until the sound changes to dull
mark the spot (usually 5th intercostal space)
find abd tympany
percuss up towards MCL
mark spot where it changes from tympany to dull

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11
Q

normal liver span

A

6-12 cm

mean liver span for males 10.5
mean liver span for females 7

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12
Q

positive spleen percussion sign

A

a change in percussion from tympany to a dulls sound with inspiration

indicates splenomegaly

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13
Q

two special tests to determine if abd filled with fluid or air

A

fluid wave

shifting dullness

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14
Q

fluid wave exam

A
  • stand at persons right side
  • place ulcer edge of examiners hand (or the patients hand) firmly on the abd in the midline
    (this stops transmission across the sin of the upcoming tap)
  • give flanks a firm strike
  • if ascites is present, the blow will generate a fluid wave through the abd
  • if abd is distended from gas or adipose tissue, you will feel no change
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15
Q

ascites occurs with:

A 
HF
portal HTN
cirrhosis
hepatitis
pancreatitis
cancer
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16
Q

when placating the abd, when is pain normal

A

mild tenderness normally present in sigmoid colon

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17
Q

spleen palpitation

A
  • Normally spleen is not palpable
  • Must be 3x normal size to be felt
  • Felt by putting and on 11th and 12th rib on back
  • Place hand on LUQ pointing toward left axilla
  • Pt takes deep breath, you should feel nothing firm
  • If you feel large spleen, do not continue to palpate
    (an enlarged spleen is friable and can rupture easily)
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18
Q

The spleen enlarges with:

A

mononucleosis
trauma
leukemias
HIV infection

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19
Q

kidney palpation

A
  • Hands together in “duck-bill” position
  • Hands at flank position
  • Press hands together firmly
    (you need deeper palpattio then used its liver or spleen)
  • Ask person to take deep breath
  • In most people, will feel no change
  • Occasionally may feel lower pole of R kidney
  • Left kidney sits 1cm higher than R kidney and is not palpable normally
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20
Q

Normal aorta size

A

2.5-4 cm wide in adult

pulsates in anterior direction

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21
Q

abnormal aorta palpation

A

widened with aneurysm

lateral pulsation that pushes fingers apart

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22
Q

Blumberg sign

A
  • Assess when person reports abd pain or when you elect tenderness during palpation
  • Choose site away from painful area
  • Hold hand at 90 degrees
  • Push down slowly and deeply
  • Then lift up quickly
  • This makes structures that indented by palpation rebound suddenly
  • A normal response is no pain on release
  • Perform at end of exam because is may cause severe pain and muscle rigidity
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23
Q

Blumberg sign

abnormal

A
  • Pain on release of pressure confirms rebound tenderness
  • Reliable sign of peritoneal inflammation
  • Peritoneal inflammation accompanies appendicitis
  • Cough tenderness that is localized to a specific spot also signal peritoneal irritation
24
Q

Murphy Sign

A
  • Hold fingers under liver border
  • Ask person to take deep breath
  • Normal response is to complete deep breath w/o pain
  • Normally palpation the liver causes no pain
  • In person with inflammation of the gallbladder, pain occurs
  • When test is positive, as the descending liver pushes the inflamed gallbladder onto the examining hand, the person feels harp pain and abruptly stops inspiration midway
25
Q

Iliopsoas muscle test

A
  • Perform when acute abd pain of appendicitis is suspected
  • Person is supine
  • Lift R leg straight up, flexing at hip
  • Push down over the lower part of the R thigh as the person tries to hold the leg up
  • Test is negative when person feels no change
  • Test is positive when pain felt in RLQ. Iliopsoas muscle is inflamed (which occurs with a inflamed or perforated appendix)
26
Q

obturator test

A
  • Lift person R leg, flexing at hip, 90 degrees at the knee
  • Hold ankle and rotate leg internally and externally
  • There should be no pain
  • An inflamed appendix irritates the obturator muscle and leg movement produces pain
  • This test is less specific
27
Q

MANTRELS score

A 
Migration to R iliac fossa
Anorexia (or Acetone in urine)
N/v
Tenderness RLQ
Rebound tenderness
Elevation of temp
Leukocytosis >10
Shift to the left >75% neutrophils

a score of >7 increases the probability of appendicitis

28
Q

s

-Inspection

A
  • Contour of abd is protuberant (d/t immature abd musculature)
  • Skin contains fine superficial venous pattern (may be visible in lightly pigmented children up to age of puberty
  • umbilical stump dries within a week, hardens, falls off by 10-14 days
  • skin covers umbilical area in 3-4 wks
  • abd shows respiratory movement
29
Q

In infants, abd should be symmetric, although two bulges are common. What are they

A

UMBILICAL HERNIA:

  • appears at 2-3 wks
  • especially prominent when infant cries
  • hernia reaches max size at 1 month
  • usually disappears by 1 year

DIASTASIS RECTI

  • separation of the rectus muscles with a visible bulge along the midline
  • condition more common with African Am. infants
  • usually disappears by early childhood
30
Q

Infants

-auscultation

A

yields only bowel sounds
metallic tinkling of peristalsis
no vascular sounds should be heard

31
Q

Infants

-percussion

A

tympani over the stomach
dullness over liver
spleen is not percussed
normal to percuss dullness over bladder (may extend up to umbilicus)

32
Q

Infant

- palpation

A
  • Aid palpation by flexing the baby’s knees with one hand while palpating with the other
  • May hold upper back and flex neck slightly with one hand
  • Liver fills up the RUQ (normal to feel liver edge at right costal margin)
  • May palpate the spleen tip and body kidneys and bladder
  • Easily palpated are the cecum and sigmoid colon
33
Q

Infants

-abnormal findings

A
  • Scaphoid abd shape occurs with dehydration
  • Dilated veins
  • Presence of one artery in umbilical cord
34
Q

Normal stools of breastfed babies vs formula

A

breastfed= golden yellow pasty, smell like sour milk

formula = brown yellow, firmer and more fecal smelling

35
Q

The child

- normal assessment

A

4 yrs abd potbelly when standing, but flat when supine

  • Abd breathing until age 7
  • Liver remains palpable 1-2cm below R costal margin
  • Spleen easily palpable
  • Usually feel R kidney and tip of L kidney

Percussion of liver

  • 3.5cm at age 2
  • 5cm at age 6
  • 6-7cm during adolescence
36
Q

The Aging Adult

- assessment

A
  • Deposits of subcutaneous fat on abd and hips
  • Abd musculature is thinner and has less tone
  • In absence of obesity, may note peristalsis
  • Organs may be easier to palpate
  • Liver is easy to palpate
  • Kidneys are easier to palpate
37
Q

Abdominal Distention- Obesity and assessment

A

Inspection: uniformly rounded, umbilicus sunken (it adheres to peritoneum, layers of fat are superficial to it)
Auscultation: normal bowel sounds
Percussion: tympany. scattered dullness over adipose tissue
Palpation: normal, may be hard to feel through thick abd wall

38
Q

Abdominal Distention- Air or Gas assessment

A

Inspection: single round curve

Auscultation: depends on cause of gas (decreased or absent bowel sounds with ileum) hyperactive with early intestinal obstruction

Percussion: tympany over large area

Palpation: may have muscle spasm of abd wall

39
Q

Abdominal Distention- Ascites

  • inspection
  • auscultation
A

inspection: single curve, everted umbilicus, bulging flanks when supine, taut glistening skin, recent weight gain, increase in abd girth
auscultation: normal bowl sounds over intestines. diminished over ascetic fluid

40
Q

Abdominal Distention- Ascites

  • percussion
  • palpation
A

percussion:
tympany at top where intestines float
dull over fluid
produces fluid wave and shift dullness

palpation
taut skin
increased intra-abdominal pressure limit palpation

41
Q

Clinical portrait of intestinal obstruction

pg 569

A

Hx of previous abd surgery with adhesions
vomiting
absence of stool or gas passage
distended abd (after 2nd day)
hyperactive bowel sound in early obstruction
hypoactive or silent in late obstruction
dehydration and loss of electrolytes
accumulation of fluid and gas in bowel proximal to obstruction
colicky pain from strong peristalsis above the obstruction
fever
pressure from excess fluid and gas
fluid and gas may leak into peritoneum
Hypovolemic shock (decrease BP, increase HR, cool skin)
x-ray shows dilated air filled loops of small bowel with multiple air fluid levels

42
Q

Common sites of referred abd pain (pg 570)

Liver

A

Right shoulder

Hepatitis may have mild to moderate dull pain in RUQ or epigastrium along with anorexia, nausea, malaise, low grade fever

43
Q

Common sites of referred abd pain (pg 570)

Gallbladder

A

sudden pain in RUQ, may radiate to right or let scapula that builds over time after ingestion of fatty foods, alcohol, caffeine
right mid back

will have positive Murphy sign

44
Q

Common sites of referred abd pain (pg 570)

Pancreas

A

mid epigastric pain
Left shoulder
Mid lower back

45
Q

abnormal bowel sounds

succussion splash

A
  • Unrelated to peristalsis
  • Very loud splash osculated over the upper abd when infant is rocked side to side
  • Indicates air and fluid in the stomach (as seen with pyloric obstruction or large hiatus hernia)
46
Q

Marked peristalsis together with projectile vomiting in newborn suggests:

A

pyloric stenosis, an obstruction of the pyloric valve of the stomach
Congenital defect
Appears in 2nd or 3rd week

47
Q

venous hum

A
  • Rarely occurs
  • Heard in periumbilical region
  • Originates from inferior vena cava
  • Medium pitch, continuous sound, pressure on bell may obliterate it
  • May have palpable thrill
  • Occurs with portal HTN and cirrhotic liver
48
Q

an enlarged liver occurs with:

A 
fatty infiltration
portal obstruction
cirrhosis
high obstruction of inferior vena cava
lymphocytic leukemia
49
Q

an enlarged nodular liver occurs with:

A

late portal cirrhosis
metastatic cancer
tertiary syphilis

50
Q

aortic aneurysm

A
  • Most are located below the renal arteries and extend to the umbilicus
  • Focal bulging >5 cm is palpable in about 80% of cases
  • Feels like pulsating mass in upper abd just left of midline
  • will hear a bruit
  • Femoral pulses are present but decreased
51
Q

Ascites is defined as

A

An abnormal accumulation of serous fluid within the peritoneal cavity.

Ascites is free fluid in the peritoneal cavity.

52
Q

Pyloric stenosis is a

A

congenital narrowing of the pyloric sphincter.

53
Q

The four layers of large, flat abdominal muscles form the:

A

ventral abdominal wall.

54
Q

pyrosis is:

A

a burning sensation in the upper abdomen

Pyrosis (heartburn) is a burning sensation in the esophagus and stomach from reflux of gastric acid

55
Q

Peritoneal Friction Rub

-abnormal vascular sound

A

Peritoneal Friction Rub
Sounds like two pieces of leather rubbed together
Indicates peritoneal inflammation
Occurs over the liver and spleen

56
Q

Arterial bruit

-abnormal vascular sound- what does it sound like, what does it mean

A

Arterial bruit

Indicates turbulent blood flow and could indicate an aortic aneurysm

57
Q

Rovsing’s sign

A

Press deeply and evenly in LLQ for 5 seconds

Abdominal pain felt in RLQ is abnormal

RN Nursing (3 decks)

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