Oropharyngeal Suctioning : Describe- moderate amount thick tan secretions
Med List: Albuterol inhaler, Prednisone, Theophylline
Sounds, masses, tenderness
Divide into four quadrants: RUQ, RLQ, LUQ, LLQ
Inspect then auscultate
Bowel sounds: absent, hypoactive, hyperactive
Listen continuously for 5 minutes to determine absence
Palpate and/or percuss after listening
Abdomen should be soft, non-tender, non-distended
RUQ – liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of colon, ascending /transverse colon, right kidney
LUQ – stomach, spleen, body of pancreas, left kidney, splenic flexure of colon, transverse/descending colon
RLQ – cecum, appendix, right ovary, tube, ureter, and spermatic cord
Midline – aorta, uterus, bladder
Epigastric, umbilical, suprapubic
Different Sequence of Assessment
Have patient empty bladder
Position patient supine with knees slightly flexed
Note the abdominal shape and contour.
The abdomen should be flat to rounded in people of average weight.
A protruding abdomen may be due to obesity, pregnancy, ascites, or abdominal distention.
A slender person may have a slightly concave abdomen
Abdomen - Inspection
Lesions – benign, scars from sx or trauma, striae, etc.
Distention - can be from fluid, air, mass, or obstruction
Pulsations - or movement of abdominal wall from peristalsis, pulsations and respiratory movement
Peristalsis usually can’t be seen. If seen, slight wavelike motions.
Visible rippling waves may indicate bowel obstruction -reported immediately.
In thin pts, abdominal aortic pulsations may be seen in the epigastric area.
Marked pulsations may indicate HTN, Aortic insuff, AAA, or other condition causing widening pulse pressure (see next slide)
Note vascular sounds – presence of bruits over aorta, renal, iliac, femoral
Normally no bruits noted
Abdominal aortic aneurysm – surg emerg.-tx immed to prevent hemorrhage, shock, and death
If you see bounding pulsation on abd wall, feel for pulsations, and measure (greater than 6 cm- most likely aneurysm) report.
Auscultation of Bowel Sounds
no BS for 5 min
less than 5/min
5-30 per min
> 30 /min
Abdomen - procedure
Use diaphragm of stethoscope lightly on skin to prevent stimulating bowel sounds
Start in RLQ (BS often present here) then proceed all four quadrants
Listen for 3-5 minutes
Note character and frequency of BS
Normal BS are high-pitched, gurgling noises caused be air mixing with fluid during peristalsis. The noises vary in frequency and pitch, and intensity. They are loudest before meal times. Normal BS – 5-30 per minute
Borborygmus, or stomach growling – are the loud, gurgling, splashing bowel sound heard over the large intesting as gas passes through it.
Hyperactive BS - > 30 /min – loud, high pitch, tinkling that occur frequently – may occur with diarrhea, constipation, and laxative use
Hypoactive < 5 per min ; - occur infrequently – assoc. with bowel obstruction, ileus, peritonitis, and indicate diminished peristalsis. (paralytic ileus, use of narc meds can decrease peristalsis)
Absent, no BS for 5 minutes.
Be sure to allow enough time for listing in each quadrant before you decide that bowel sounds are absent. If NGT to suction, turn off suction as to not obscure or mimic sounds
-Density of abdominal contents
-Screen for abnormal fluid or masses
Tympany – predominantly over the abdomen – gas-filled
Dull over organs in the abdominal cavity (liver, spleen)
CVA tenderness Costovertebral Angle CVA tenderness – positive in pyelonephritis
Abdomen - Palpate
Palpate all four quadrants:
To check for muscle resistance or rigidity; masses, fluid, tenderness.
To palpate, put finger of one hand close together and make gentle rotating movements as you depress ½ inch (1.3 cm) Light palpation – depress 1 cm:Relaxation; Tenderness; Masses
Palpate areas of pain and tenderness last
Normal : the abd should be soft and nontender. As you palpate, note any
Abnormal findings : tenderness, masses, and rigidity
TENDERNESS, MASSES, RIGIDITY
Deep palpation - depress 5-8 cm; that’s about 2-3 inches.
In obese, patient, put one hand over the other and push down.
Palpate the entire abd on a clockwise direction and not any: Tenderness; Masses; Enlarged organs
Normally Palpable Structures
Know what is underneath so you can determine what can be expected from normal to abnormal
Ex. suprapubic distention, full bladder or tumor?
Sigmoid colon, stool can be palpated there
Liver – should not be able to palpate liver way below the rib = enlarged
Use when found abdominal pain or tenderness
Hold hand at 90 deg angle & push slowly & deeply
Lift hand quickly
Norm. response is no pain on release of pressure
Perform at end
AUSCULTATE FOR BOWEL SOUNDS IN 4 QUADRANTS FOR 2-5 MIN & DETERMINE IF AUDIBLE, ABSENT, HYPOACTIVE, HYPERACTIVE
PERCUSS FOR TYMPANY & LIVER DULLNESS
PALPATE LIGHTLY FOR TENDERNESS, MASSES, RIGIDITY
ASSESSMENT OF HEAD & NECK http://e-courses.cerritos.edu/rsantiago/My%20Webs/ASSESSMENT%20OF%20HEAD%20&%20NECK_SP%2004.ppt
Health History and Physical Assessment http://e-courses.cerritos.edu/rsantiago/My%20Webs/PowerPoint%20Presentations.htm
Rachel S. Natividad, RN,MSN: Assessment of the Abdomen http://e-courses.cerritos.edu/rsantiago/My%20Webs/ASSESSMENT%20OF%20THE%20ABDOMEN%20N212_n251%20SP04.ppt
Rachel S. Natividad, RN,MSN: Assessment of the Heart, Great vessels of the neck, and Peripheral Vascular system http://e-courses.cerritos.edu/rsantiago/My%20Webs/Cardiovascular%20Assessment%20_N212_N251%20SP04.ppt
Rachel S. Natividad, RN, MSN:The Respiratory System, Thorax and Lungs