abdominal assessment

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Right upper quadrant: ascending & transverse colon
duodenum
gall bladder
hepatic flexure of the colon
liver
pancreas (head)
pylorus
right adrenal gland
right kidney (upper pole)
right ureter
Right lower quadrant: appendix
ascending colon
cecum right kidney (lower pole)
right ovary and tube
right ureter
right spermatic cord
Left upper quadrant: left adrenal gland
left kidney ( upper pole)
left ureter
pancreas
spleen
splenic flexure of colon
stomach
transverse and descending colon
left lower quadrant: left kidney (lower lobe)
left ovary and tube
left ureter
left spermatic cord
descending and sigmoid colon
midline: bladder
uterus
prostate gland
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
and
endocrine gland
The functions of the liver ?: accessory digestion organ
metabolic and regulatory functions
Largest solid organ?: Liver
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.

TRICK QUESTION.
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
digest microorganisms
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 ?: obstruction
Aspirin, ibuprofen, and steroids can cause what side effects on the stomach?: may cause gastric bleeding.
iron supplements can cause?: constipation
weight loss and fatigue is associated with ?: cancer and chronic intestinal disorders.
gall bladder cancer risks age? sex? nationality?: >70 years old
female after menopause
native American
typhoid carrier
obesity
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?: burns
bluish or purple discoloration around the umbilicus indicates?: intra-abdominal bleeding
A deviated umbilicus could be caused by? List five.: pressure from a mass
enlarged organs
hernia
fluid
scar tissue
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.: fat
fluid
fetus
flatulence
fibroids
feces
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?: male
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?: abnormal
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?: bell
to auscultate friction rubs the nurse uses the _____________of the stethoscope?: diaphragm
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?: elderly
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?: functional
unilateral exaggerated thoracic convexity increases in what type of scoliosis?: structural
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? List four: injury to the soft tissue
osteoarthritis
ankylosing spondylitis
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?: scoliosis
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 ?: dislocation
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?: enlarged
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?: diaphragm
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 ?: diarrhea
gastroenteritis
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?: No
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? abnormal: 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
bulging flanks
everted umbilicus
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?: cancer
an enlarged, non-tender liver suggest ?: cirrhosis
an enlarged tender liver suggest?: CHF
acute hepatitis
or abscess
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
bruits
diaphram of the scope is used to hear?: friction rubs
bowel sounds
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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