This document describes a nurse named Budek assessing an elderly patient named Aling Ester who presented with abdominal pain. Budek performed an abdominal examination in the correct order of inspection, auscultation, percussion, and palpation. Abnormal findings included dehydration and a mass in the left lower quadrant. Budek disagreed with the doctor's order for a fleet enema due to risk of further dehydration. Budek instead ordered a normal saline enema and positioned the patient in left sims position to facilitate evacuation. The enema produced large hardened stool, relieving the patient's pain.

1. Abdominal Assessment: A story towards mastery
Abdominal Assessment: A story towards mastery
By : Budek
http://www.pinoybsn.tk
Nag mumuni muni si Nars Budek sa emergency unit ng Ospital ng Fatima medical center. Bigla biglang
may pumasok na pasyente para sa admission. Masakit raw ang kanyang tyan.
Inobserbahan siya ni Nars Budek. Aba, napakabilis ng kanyang pag hinga. Namumutla pa ang kaniyang
mga labi at parang tuyong tuyo at nagbabakbak.
“Ang bilis rin ng kanyang heart rate ah, 110 bpm, tachycardic ito, siguro may masamang nararamdaman
o may nararamdamang sakit?” Ang naisip ni Budek.
Ang pasyente natin ay si nanay ester, isang matandang pasyente. Siya ay 74 taong gulang na na may
chief complaint na “MASAKIT ANG TIYAN KO”
What are the possible causes of abdominal pain in the elderly ?
Nurse Budek thinks of : Constipation? Gas accumulation? Impaction? Inflammatory Bowel
Disease? Appendicitis? Cholecystitis? Cholelithiasis? Ulcers? Peritonitis? Colon cancer? Ovarian
or uterine cancer? PID? And many many more.
“Okay nanay, dadalhin ko muna po kayo sa lab para po sa isang work up.”
Hmm… work up? Did nanay ester understands what nurse budek said…. WORK UP? Perhaps,
this will be better :
“Okay nanay, pupunta na po tayo sa laboratoryo para po maisagawa natin ang ibat ibang pagsusulit
upang malaman kung ano po ang sanhi ng pananakit ng inyong tiyan.”
Natanggap na ni Nars Budek ang mga laboratory results. Hmmm, 13 mg/dl ang kanyang hemoglobin at
56% ang kanyang hematocrit. Ang potassium level nya ay nasa 5.0 meq/L. Ang WBC nya ay nasa 8,000 /
cc3. Wala namang diprensya ang kanya lab results ah.
Really? Are you sure that all the lab results are normal? Let us review the normal values :
WBC : 8,000 / cc3 is normal. An increase beyond 10,000 / cc3 is indicative of infection.
Hgb : Hemoglobin levels of aling ester are within normal limits. Meaning, there is no or minimal
bleeding.
Hct : Hematocrit levels of aling ester are high, indicating that she is dehydrated or bleeding.
K : The potassium level is within the normal limits of 4.5 to 5.5 meq/L.
Using the selected lab results above, we can then eliminate many possible causes of the
abdominal pain of aling ester. Remove : PERITONITIS, APPENDICITIS, INFECTION,
INFLAMMATORY BOWEL DISEASE AND ULCERS.
“Aling ester halika po at humiga po kayo rito at titingnan ko po ang inyong tiyan.”
Did Nurse Budek use an effective approach on asking aling ester to lie down for an abdominal
assessment?
How about this :
“Aling ester, Abutin nyo po ang kamay ko. halika po kayo rito at aalalayan ko kayo papunta dito sa higaan
para po tingnan ko ang inyong tiyan.”
The client is age 74 and in PAIN. It is NOT therapeutic to ask the client to come and lie down
on the examiners table on her own.
“Aling ester, mahiga po kayo dito at titingnan ko po kayo.”
What should be aling esters position for an abdominal assessment?

2. A. Supine, with head and feet FLAT on bed
B. High fowlers with the feet in extension
C. Prone position
D. Low fowlers with the knee on flexion
“Aling ester, itataas ko na po ng kaunti ang ulo ninyo at paki baluktot po lamang ang inyong tuhod.”
Correct answer is LETTER D. To promote abdominal relaxation, The head of the bed should be
SLIGHTLY elevated and the knee of the client on flexed position.
A and B will promote abdominal rigidity making it hard for Nurse Budek to PALPATE the
abdomen.
If your answer is C, you should try to imagine how can you assess the patient’s abdomen if she
is in prone position?
Humiga na si aling ester at mag uumpisa na si Nurse Budek sa pag assess ng tiyan ni aling ester.
What should be Nurse Budek’s INITIAL STEP in assessing aling ester’s abdomen?
A. Palpation
B. Inspection
C. Auscultation
D. Percussion
Tiningnan ni Nurse Budek ang tiyan ni aling ester, Hmm.. wala namang kakaiba sa tiyan ni aling ester.
Round sha, may mga stretch mark marahil dulot ng kanyang pagbubuntis at panganganak. Lubog ang
pusod at malinis naman ito. Wala naman akong nakikitang gumagalaw galaw mukhang maaliwalas at
tahimik naman ang kanyang tiyan kung titingnan.
Kinuha ni Nurse Budek ang stethoscope at kanyang pinakinggan ang tiyan ni aling ester. “Aba eh! Wala
akong marinig na kung ano man. Hypoactive ang bowel sound ni aling ester. Sa loob ng isang minuto ay
nakarinig ako ng tatlong bowel sound.”
How did Nurse Budek concluded that aling ester’s bowel sound is hypoactive?
A. The bowel sounds are more than 35 per minute
B. There is NO bowel sounds on aling ester’s assessment
C. There is less than 5 bowel sounds per minute on the assessment
D. The bowel sounds are less than 15 per minute
Sa isip ni Nurse Budek, “Ang normal bowel sounds ay 5-35, nabasa ko iyan kay saunders nung akoy nag
aaral pa! Kawawa naman si nanay, mukhang constipated ata ah?”
“Teka nga I auscultate ko dito sa ILEO-CECAL VALVE para maka sigurado sa aking bilang.”
Where is the ILEO-CECAL VALVE?
A. Left lower quadrant
B. Right lower quadrant
C. Left upper quadrant
D. Right upper quadrant
Why did Nurse Budek use the ILEO-CECAL VALVE Location to further assess aling esters bowel
sounds?
A. Because that is the location where bowel sounds are produced
B. The ICV is the only location in the large intestine where bowel sounds are heard
C. Bowel sounds are always heard in the ICV more than any other quadrants
D. ICV is located in the small intestines, it is where gas are formed and release giving a
gurgling sound
Nilagay ni Nurse Budek ang kanyang steth sa may RIGHT LOWER QUADRANT upang marinig ang tunog sa
may ileo-cecal valve kung saan, parati itong mayroong bowel sounds kumpara sa ibang abdominal
quadrant.

3. “ I percuss ko na nga ang tiyan ni nanay. Tingnan natin kung marami ng laman laman ito. “
Sa pag percuss ng tiyan ni aling ester, Nakarinig si Budek ng isang DULL o mababang tunog sa may LEFT
LOWER QUADRANT ni aling Ester. “ Aha, mukhang meron ditong isang hindi kanais nais na bagay ah. “
What are the different sounds that Nurse Budek can percuss on aling Ester’s abdomen?
1. DULLNESS : May be percussed on the R U Q because of the Liver and in the L U Q because of
the spleen.
An impaction of feces also produce a DULL sound on percussion.
2. HYPERRESONANCE/RESONANCE : An over inflated area such as the LUNGS can produce a
hyperresonanec/resonant sound.
3. FLAT : FLUID sounds FLAT on percussion. Usually heard on bowel obstruction due to
volvulus, diverticulosis/litis and intussusception.
4. TYMPANY : The TUNOG TAMBOL, is heard when the intestine or stomach is air filled.
At sa huling bahagi, kinapa [ PALPATION ] ni Nurse budek ang tiyan ni aling ester. Nag umpisa siya sa
Right lower quadrant, papuntang right upper quadrant hanggang makakapa siya ng isang maliit at
matigas na mass sa may left lower quadrant ni aling ester.
“ Ito yung dull na narinig ko kanina “ Ang nasabi ni Budek.
Why did Nurse Budek follows : INSPECTION, AUSCULTATION, PERCUSSION AND PALPATION in
exact and correct order in assessing aling esters abdomen?
A. Doing Percussion and Palpation last will help limit stimulation of bowel sound therefore, An
accurate assessment of the abdominal status is recorded.
B. Inspection and Ausculation are done first as not to cause PAIN on aling ester that will
prevent her from not cooperating with the abdominal assessment.
C. Palpation is done last on an elderly client because of the sensitivity of the abdominal muscle
that might cause severe discomfort to aling ester.
D. Inspection is done first as to directly observe the general status of aling ester’s abdomen
before doing specific assessments of each quadrants.
“Hayyy, Mukhang alam ko na aling ester kung bakit masakit ang tiyan natin ha.” Ang sabi ni Nurse Budek.
“Ay,!!” sa loblob ni Budek. “May hanging question nga pala tayo. Bakit nga ba hinuli ko ang palpation at
sinunod ang step na I,A,PE,PA. O “ I am PePa.” Kasi nga, pag pinalpate ko agad, ma ii stimulate ko ang
bowel sound ni nanay kaya hindi accurate ang bowel sound na maririnig ko, hindi ko masasabi na HYPO o
HYPERACTIVE ang bowel sound ni nanay dahil na apektuhan ng percussion o palpation. Hindi ba,
manipulation increases peristalsis, baka mamaya mag 30 pa ang bowel sounds ni nanay ester at hindi
maging tama ang aking palagay na kaya masakit ang tiyan nya dahil hypoactive ang pag galaw ng
kanyang bituka at CONSTIPATED SIYA.”
“Nanay ester, kailan po kayo huling nadumi?” Ang tanong ni Nurse Budek.
“Abay hindi ko na matandaan iho. Malamang isang linggo na akong hindi nadudumi eh, iyon ba ang
dahilan bakit masakit ang aking tiyan? “ Ang sabi ni aling ester.
“Abay opo nanay, dapat po Isang dumi kada dalawang araw po ang pinaka mababa ninyong pag dumi,
sabi po iyan sakin ng aking bestfriend na si Lippinncott “ Sabi ni Nurse Budek.
“Nay, Ang dry dry naman niyang bibig nyo. Umiinom po ba kayo ng maraming tubig sa isang araw? “ Sabi
ni Nurse Budek
“Abay oo naman ano, marami akong iniinom na tubig sa isang araw.”
Did Budek asked the right question? Let us see if this question is better….
“Nay, ang dry dry naman niyang bibig nyo, Ilang baso po bang tubig ang iniinom nyo sa isang araw?” Ang
tanong ni Nurse Budek.

4. “Nakaka tatlong baso ako sa isang araw, sapat na ba iyon?” tugon ni aling ester.
“ Nay, dapat po 6-8 glassess ang iniinom natin bawat araw. Kaya naman pala hindi kayo madumi ng
regular walang panulak at dulas ang inyong bituka eh. “ Sagot ni Nurse Budek.
Ibinahagi ni Budek ang kanyang natuklasan kay Doctor tuklaw na nangangalaga kay aling ester. Ipinag
utos ng doktor ang Fleet enema kay aling ester ngunit nag reklamo si Nurse Budek.
Why did Nurse Budek reacted and disagreed to the doctors order of fleet enema?
A. Fleet enema is contraindicated among elderly
B. Fleet enema can cause dependence
C. Fleet enema will causes fluid overload
D. Fleet enema will cause further dehydration
“Doktor, san ba kayo graduate? Bat fleet enema eh tanda tanda na ni nanay dehydrated pa.. gusto nyong
lalong ma dehydrate si nanay?” Ang matapang na sagot ni Budek
“Ah ganun ba? Ano ba dapat?” Sabi ni Dr. Tuklaw
“ Kasi hypertonic saline ang fleet, Each 118-mL delivered dose contains 19 g monobasic sodium phosphate
monohydrate and 7 g dibasic sodium phosphate heptahydrate. Kung hypertonic sha imagine, sisipsipin
nito ang tubig sa large intestine ni nanay at lalong matutoyo si nanay. Baka ma cardiac arrest pa yan due
to hypokalemia sige ka. “ Ang mayabang na sabi ni budek.
“ I NSS enema ko nalang di kaya tap water, mamili ka dok ano ang gusto mo?” Ang tugon ni Budek.
“Bahala ka sa buhay mo” Ang tugon ni Dr. Tuklaw
“ Ok , I order mo ako ng NSS enema para wala tayong problema sa fluid and electrolate balance” Ang
tugon ni Budek.
“ Yes doc, masusunod po “ Ang sagot ni Dr. Tuklaw
Binalikan ni Nurse Budek si nanay ester sa kanyang silid.
“ Nanay ester, Ready ka na ba sa gagawin natin?” Sabi ni Budek.
“ Oo, ready na.. masakit ba yan? Ano ba ang gagawin mo sa akin?” Ang tugon ni aling ester.
“ Bali papalabasin mo natin ang mga dumi po ninyo na naiwan at bumara na diyan sa inyong bituka para
po hindi na kayo masaktan at maisayos po natin ang normal na pag dumi ninyo “ Ang sagot ni budek.
“ Nay, pumuwesto na po kayo. …….”
What should be aling ester’s postion when preparing to give an enema?
A. Left sims position
B. Prone position
C. Right sims position
D. Dorsal Recumbent position
“ Nay, pumuwesto na po kayo. Tumagilid po kayo at humiga sa inyong kaliwa at I baluktot niyo po ang
kanang tuhod ninyo [ LEFT SIMS POSITION ], Tulungan ko po kayo” Ang sabi ni Nars Budek.
“ Bakit ganito pa dapat ang aking posisyon? Ano ang importansya nitong ganitong posisyon nurse?” Ang
tanong ni aling Ester.
Why is the patient positioned in the LEFT SIMS position when administering an enema?
A. The Left sims position will facilitate descent of the solution towards the rectum and the
colon
B. The Left sims position is used to prevent injury to the bladder when inserting the enema
tube
C. The Left sims position will prevent the solution from going into the kidneys that will cause
hydronephrosis

5. D. Female clients are put in the LEFT SIMS position to prevent leakage of the solution towards
the cervix that will cause sever inflammatory reaction.
“Nay, kasi po ang rectum po natin ay PABABA pag tayoy naka left sims. Kung naka right sims ka eh
babalik lang po yung tubig palabas dahil po paangat po ang kaalangan niyang daluyan, hindi po siya
makakarating ng tama sa colon” Ang tugon ni Budek. [Refer to the normal anatomy of the large intestine]
At nang matapos na ni Nurse Budek ang pag I enema kay nanay, Limang malalaking bilog bilog na
kasinglaki ng chico ang kanyang nakuha at matapos nito, malalambot na ang dumi na lumabas kay nanay
Ester.
“Hayyy, gumaan na ang aking pakiramdam Nurse Budek, salamat sa tulong mo ha.. hindi na siya
masakit” Ang pasasalamat ni nanay Ester.
Ngumiti si budek sabay bigkas “ Nay, tandaan… tubig tubig tubig at masustansya at balanseng pagkain na
mataas sa fiber tulad ng gulay at prutas para hindi na mangyari iyan ulet sa inyo. ”
Napangiti si aling ester at siya ay parang nasalangit sa gaan ng kanyang pakiramdam at ginhawang
nararamdaman.
Follow up questions :
Answer the following questions :
1. What is the minimum and maximum height of the enema can?
2. How long should budek insert the rectal tube? What kind of lubricant should he use?
3. What should be nurses budek’s first intervention in case cramping occurs during enema instillation?
4. When should nurse budek STOP irrigating aling ester’s colon?
5. What are the contraindications when administering an enema?

6. D. Female clients are put in the LEFT SIMS position to prevent leakage of the solution towards
the cervix that will cause sever inflammatory reaction.
“Nay, kasi po ang rectum po natin ay PABABA pag tayoy naka left sims. Kung naka right sims ka eh
babalik lang po yung tubig palabas dahil po paangat po ang kaalangan niyang daluyan, hindi po siya
makakarating ng tama sa colon” Ang tugon ni Budek. [Refer to the normal anatomy of the large intestine]
At nang matapos na ni Nurse Budek ang pag I enema kay nanay, Limang malalaking bilog bilog na
kasinglaki ng chico ang kanyang nakuha at matapos nito, malalambot na ang dumi na lumabas kay nanay
Ester.
“Hayyy, gumaan na ang aking pakiramdam Nurse Budek, salamat sa tulong mo ha.. hindi na siya
masakit” Ang pasasalamat ni nanay Ester.
Ngumiti si budek sabay bigkas “ Nay, tandaan… tubig tubig tubig at masustansya at balanseng pagkain na
mataas sa fiber tulad ng gulay at prutas para hindi na mangyari iyan ulet sa inyo. ”
Napangiti si aling ester at siya ay parang nasalangit sa gaan ng kanyang pakiramdam at ginhawang
nararamdaman.
Follow up questions :
Answer the following questions :
1. What is the minimum and maximum height of the enema can?
2. How long should budek insert the rectal tube? What kind of lubricant should he use?
3. What should be nurses budek’s first intervention in case cramping occurs during enema instillation?
4. When should nurse budek STOP irrigating aling ester’s colon?
5. What are the contraindications when administering an enema?