Glossary of abdominal assessment
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- Right upper quadrant
- ascending & transverse colon
hepatic flexure of the colon
right adrenal gland
right kidney (upper pole)
- Right lower quadrant
cecum right kidney (lower pole)
right ovary and tube
right spermatic cord
- Left upper quadrant
- left adrenal gland
left kidney ( upper pole)
splenic flexure of colon
transverse and descending colon
- left lower quadrant
- left kidney (lower lobe)
left ovary and tube
left spermatic cord
descending and sigmoid colon
- outer most layer of the abdominal wall
- external abdominal oblique
- middle layer of the abdominal wall
- internal abdominal oblique
- the inner most layer of the abdominal wall?
- transverse abdominis
- The location of the liver ?
- fills most of the RUQ
composed of 4 lobes
extends to the left mid clavicular line
extends just below the right coastal margin( where it can be palpated)
- If palpable the liver an be described as having a ?
- soft consistency
- Where is the pancreas located?
- behind the stomache
deep in the upper abdomen
normally not palpable
extends from the RUQ to the LUQ
- The functions of the pancreas?
- accessory organ
- The functions of the liver ?
- accessory digestion organ
metabolic and regulatory functions
- Largest solid organ?
- Where is the nurse most likely to palpate the liver?
- just below the right coastal regions
- Where can the spleen be palpated?
- normally it is not palpable.
- Where is the spleen located?
- above the left kidney, just below the diaphragm at the level of the 9th. 10th. and 11th. ribs
appr. 7 cm. wide
- Where kidney tenderness is best assessed ?
- at the costovertebral angle
- Functions of the kidneys?
- filtration and elimination of metabolic waste products.
blood pressure control
maintenance in water and electrolytes
endocrine glands by secreting hormones.
- Functions of the spleen?
- filter the blood of cellular debris
return the breakdown products to the liver
- What is the onset for pain produced by acute pancreatitis?
- sudden onset
- Pancreatic cancer pain begins as ?
- gradual or reacurrent
- If upon auscultation the nurse does not hear bowel sounds or decreased bowel sounds she would then?
- give an M.D. referral; it is an emergency requiring immediate attention
- Absent bowel sounds or diminished bowel sounds are associated with ?
- peritonitis or paralytic ileus.
- High pitched tinkling and rushes of high pitched sounds accompanied by abdominal cramping are associated with ?
- Aspirin, ibuprofen, and steroids can cause what side effects on the stomach?
- may cause gastric bleeding.
- iron supplements can cause?
- weight loss and fatigue is associated with ?
- cancer and chronic intestinal disorders.
- gall bladder cancer risks
- >70 years old
female after menopause
- what is the first thing a client should do to prepare for an abdominal examination?
- empty bladder
- Where should the clients arms be during the abdominal exam?
- at their side or on their chest.
- purple discoloration at the flanks could indicate?
- bleeding within the abdominal wall from trauma to the kidneys, pancreas, duodenum, or from the pancreatitis
- dark bluish-pink striae is associated with?
- Cushing's syndrome
- deep irregular scars may result from?
- bluish or purple discoloration around the umbilicus indicates?
- intra-abdominal bleeding
- A deviated umbilicus could be caused by? List five.
- pressure from a mass
- an everted umbilicus is seen with?
- abdominal distention
- an enlarged everted umbilicus is associated with?
- umbilical hernia
- generalized protuberant abdomen is associated with?
- gas or fluid accumalation
- distention below the umbilicus is associated with?
- full bladder.
- distention of the upper abdomen may be seen with?
- masses of the pancreas or gastric dilation
- the six F's related to abdominal distention.
- a mass within the abdominal wall is more prominent when?
- when the head is raised
- Normal abdominal respiratory movement may be seen in what clients?
- diminished abdominal respiration or change to thoracic breathing in male clients may reflect?
- peritoneal irritation
- scaphoid and distended protuberant abdomen is what type of finding?
- How would the nurse assess the abdomen for hernia or diastasis recti ?
- have the client raise their head?
- vigorous, wide, exaggerated, abdominal aortic pulsations may be seen is clients with?
- abdominal aortic aneurysm
- to auscultate bruit the nurse would use the ____________ of the stethoscope?
- to auscultate friction rubs the nurse uses the _____________of the stethoscope?
- lateral bending of the head is ?
- 40 degrees to each side.
- rotation of the head right and left is ?
- 70 degrees to each side
- hyperextension of the head is
- 45 degree
- flexion of the head is
- 55 degree
- kyphosis is a common finding in what age group?
- bending forward to touch toes
is what type of movement?
- flexion and its normal is 90 degrees:
75 to 90 is normal with a fattening of the lumbar concavity
- lateral curvature disappears in what type of scoliosis?
- unilateral exaggerated thoracic convexity increases in what type of scoliosis?
- IF assessing a clients ROM by bending side to side where would the nurse be?
- client standing
nurse behind the client stabilizing the pelvis with the nurses hands.
- lateral bending of the thoracic and lumbar should be how many degrees?
- 35 on each side
- hyperextention of the lumbar and thoracic spine?
- 30 degrees
- lateral rotation of the thoracic and lumbar spine should be ?
- 30 degrees
- Impaired ROM to the thoracic and lumbar back is generally the result of?
- injury to the soft tissue
and congenital abnormalities
- What test should be performed it the client reports lower back pain?
- Lasegue's test.
- Lower back pain that shoots and radiates down one or both legs below the knees may be caused by?
- herniated disc.
- How to perform the Laseques test = straight leg raising
- client lie flat
raise affected leg to the point of pain
at point of pain, dorsiflex the foot
ABNORMAL FINDING= pain is reproduced.
- What does the nurse do if she suspects the client has one leg longer than the other?
- measure the leg between the anterior superior iliac spine and the medial malleolus, crossing the tape on the medial side of the knee= true leg length
- unequal leg length are associated with?
- equal true leg length but unequal apparent leg lengths are seen with?
- abnormalities in the structure or position of the hips and pelvis
- muscle atrophy is seen with?
- nerve or muscle damage or lack of use.
- flat hollow or less rounded shoulders are seen with ?
- tenderness, swelling, and heat in the shoulders may be noted with ?
- shoulders strains, arthritis, bursitis, or degenerative joint disease.
- ROM of the arms
- forward flexion= arms forward is 180°
extension arms backwards is 50 degrees
adduction of the arm is 50 degrees
abduction= hand across body and over head is 180 degrees
- painful and limited abduction ( arms over head) of the arms accompanied by muscle weakness and atropy is seen with ?
- rotator cuff tear.
- Client has sharp catches of pain when bringing hands over head is associated with?
- rotator cuff injury
rotator cuff tendinitis
- chronic pain and severe limitation of all shoulder motions are seen with ?
- calcified tendinitis
- Measurements of the legs are equal if they are?
- within 1 cm
- deep palpation
- push down 5-8 cm.
assessing location, size , consistency, mobility of an organ
- If the liver is 1-2 cm. below the right coastal margin, this would be considered?
- How wide is the normal spleen?
- less than 7 cm wide.
- If a cleint state he is constipated, what should the nurse do?
- Ask what they mean by "constipated"
- to hear bowel sounds the nurse uses diaphragm or bell?
- Hypoactive bowel sounds defined as sounds heard how often?
- common after surgery
fewer than 5 sounds in one minute
- Hyperactive bowel sounds are defined as sounds heard....?
- greater than 30 sounds a minute
- Absent bowel sounds must be assessed for how many minutes before they can be documented as "absent"
- 5 full minutes
- When is hyperresonance is heard ?
- over gaseous distention
- hyperactive bowel sounds are commonly heard in a client with ?
early bowel obstruction
- hypoactive bowel sounds are common is clients ?
- returning from surgery
- If a client has a mass below the abdominal wall will the mass be visible when the client raises their head?
- a bruit?
- low pitched murmurlike sounds
- Characteristic sound and organ span of splenomegaly are?
- dullness greater than 7 cm.
- To rule out splenomegaly what else should be assessed?
- a full stomach
or feces in the colon
- to palpate the urinary bladder to nurse would ?
- begin at the pubic symphysis and move upward and outward to estimate bladder borders.
- to further assess for ascites after performing the fluid wave test, what other test would need to be performed?
- an ultrasound
- characteristics of fat
What sound is percussed?
- uniformly protuberant
wall is thick
tympany is the sound percussed
umbilicus is sunken
- characteristics of feces within the abdomen.
- localized distention
dullness is percussed
- Characteristics of fibroid and other masses
- generalized distention in lower abdomen
mass displaces bowel
dullness is percussed with tympany at the periphery
umbilicus may be everted
- Characteristics of flatus
- generalized protuberance or localized protuberance
tympany is percussed over the area
- characteristics of ascites fluid ?
- generalized protuberance
percussion reveals dullness over fluid.
percussion reveals tympany over intestines.
- What is an umbilicus hernia.
- bowel protruding through a weakness in the umbilical ring
- epigastric hernia
- bowel protrudes through a weakness in the linea alba. small bulge appears midline between the xiphoid process and the umbilicus. usually discovered only with palpation.
- diastasis recti
abnormal but not significant
- not a significate finding
bowel protrudes through a seperation between the two rectus abdominis muscles. appears at the midline ridge.
visible when the client raises their head or coughs.
- characteristics of an incisional hernia
- appears as a bulge at the surgical site
- an enlarged, firm, hard, nodular liver indicates?
- an enlarged, non-tender liver suggest ?
- an enlarged tender liver suggest?
- Where could the nurse expect bowel sounds to be more active?
- over the iliocecal valve in the RLQ
- Characteristics of an enlarged gallbladder.
- extremely tender
postive Murphy's sign
- during palpation the normal abdomen will be tender in what locations?
- over xiphoid process,liver,aorta, lower pole of the kidney, gas filled cecum, sigmoid colon, ovaries.
- venous hum is associated with?
- cirrhosis of the liver
- the bell is used to hear
- venous hums
- diaphram of the scope is used to hear?
- friction rubs
- friction rubs heard over the lower right coastal area is associated with?
- hepatic abscess
- friction rubs heard at the left axially line in the lower left coastal area is associated with?
- splenic infraction, abscess, infection, or tumor.
- abnormal dullness is heard
- over ascites,distended bladder, large masses,
- tympany or hyperresonance is heard
- over a gaseous distended abdomen
- normal dullness is heard
- over the liver and spleen
- a normal abdomen feels?
- soft, mild tenderness, no masses,
- if the liver is felt it should feel?
- firm, smooth, and even
- An enlarged spleen could be the result of ? List four.
- trauma, mononucleosis, chronic blood disorders, or cancer
- If the spenic notch is felt, this would indicate?
- splenic enlargment
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