NR 304 EXAM 2 STUDY GUIDE VERSION 2 / NR304 EXAM 2 STUDY GUIDE VERSION 2: LATEST,CHAMBERLAIN COLLEGE OF NURSING

NR 304 EXAM 2 STUDY GUIDE
Chapter 21 Abdomen

Structure and Function Abdominal Organs
 Solid Viscera-doesn’t change shape, liver, spleen, ovary
 Hollow Viscera-changes shape, stomach, intestine, bladder
 Abdominal Muscles
 Peritoneal Cavity-lines the abdomen
Visceral Peritoneum-lines organs, stressed and inflamed with appendicitis and
choleycistytis
Parietal Peritoneum-entire wall

Structure and Function Abdominal Vasculature
 Abdominal Aorta-listen for bruit for aortic aneurysm. Caused by pressure
 Renal Arteries-stenosis from plaque

Subjective Data
 Appetite/wt. change
 Dysphagia
 Abdominal Pain
 Nausea/Vomiting
 Indigestion
 Bowel Habits
 Stool Assessment
 Meds
 Nutrition
 Social Hx/Alcohol
 Past Abdominal Hx
 Stress
 Family Hx

Lifespan Considerations
 Infants & Children: Feeding & eating habits, GI function & nervous system maturation
r/t toilet training
 Pregnant Female: Nausea, constipation, heartburn (pyrosis), Linea Nigra
 Older Adult: Muscle tone, constipation, decreased peristaltic activity

Objective Data Abdomen
Inspection: Contour, symmetry, umbilicus, skin, pulsation
Auscultation: Bowel sounds (4 quadrants), vascular sounds (bruit)
Percussion: Tone (4 quadrants), *Ascites(fluid in the abdomen, becomes protuberant) flip pt to
left-have tympana on right dull on left and vice versa assessment (p. 553). –want tympana due
to gas

, Palpation: Light and deep palpation.
Special procedures:
Rebound tenderness (Blumberg at McBurney’s point) and Iliopsoas Sign-appendix, Murphy’s
Sign-gallbladder
Illeocecal valve RLQ –watery

Terms to know…
 Rectus Diastasis-separation of the rectus muscles midline. keep abdominal contents in
place, pregnant women, body builders, abd. Surgery.
 Cullen’s Sign-blue ring around umbilicus, internal bleeding
 Borborygmi-really loud bowl sounds, hungry, negative sound when auscultating
 Paralytic Ileus-and not walking. Bowel obstruction.
 Melena-Blood in stool, oxidized blood. Black tarry thick stools
 Shifting Dullness- ascites patients
 Distended/Distention-gas, ascites
 Guarding of the Abdomen-Involuntary and voluntary
 What is involved in the ongoing assessment of a client with an NG tube to suction . . .?
WHY . . .? –Drainage, aspirate gastric contents every time before you insert anything,
turn off suction container when listening to bowel sounds

Nursing Diagnoses
 Ineffective Nutrition: less than body requirements r/t nausea and vomiting
 Constipation r/t decreased fluid & fiber intake, bed rest, medications
 Risk for ineffective health maintenance r/t lack of knowledge of need for recommended
colon screenings
 Pain, acute r/t inflammatory process

What Predicts What??
 Hemoglobin 6.8
 Burning Sensation in epigastric region
 No Appetite
 Nausea/Vomiting

Test your knowledge
A client reports abd. pain. How should the nurse proceed with the assessment?
1. Deep palpation
2. Assessing the painful area first
3. Assessing the painful area last with light palpation
4. Checking for warmth at the painful area

When auscultating a clients abd. the nurse detects gurgles over the RLQ. What should the nurse
suspect?
1. Decreased bowel motility
2. Nothing abnormal