NR I304 IExam I2 IStudy IGuide
Chapter I21 IAbdomen
Structure Iand IFunction IAbdominal IOrgans
▪ Solid IViscera-doesn’t Ichange Ishape, Iliver, Ispleen, Iovary
▪ Hollow IViscera-changes Ishape, Istomach, Iintestine, Ibladder
▪ Abdominal IMuscles
▪ Peritoneal ICavity-lines Ithe Iabdomen
Visceral IPeritoneum-lines Iorgans, Istressed Iand Iinflamed Iwith Iappendicitis IandIcholeycistytis
Parietal IPeritoneum-entire Iwall
Structure Iand IFunction IAbdominal IVasculature
▪ Abdominal IAorta-listen Ifor Ibruit Ifor Iaortic Ianeurysm. ICaused Iby Ipressure
▪ Renal IArteries-stenosis Ifrom Iplaque
Subjective IData
▪ Appetite/wt. Ichange
▪ Dysphagia
▪ Abdominal IPain
▪ Nausea/Vomiting
▪ Indigestion
▪ Bowel IHabits
▪ Stool IAssessment
▪ Meds
▪ Nutrition
▪ Social IHx/Alcohol
▪ Past IAbdominal IHx
▪ Stress
▪ Family IHx
Lifespan IConsiderations
▪ Infants I& IChildren: IFeeding I& Ieating Ihabits, IGI Ifunction I& Inervous Isystem Imaturation
Ir/t Itoilet Itraining
▪ Pregnant IFemale: INausea, Iconstipation, Iheartburn I(pyrosis), ILinea INigra
▪ Older IAdult: IMuscle Itone, Iconstipation, Idecreased Iperistaltic Iactivity
Objective IData IAbdomen
Inspection: IContour, Isymmetry, Iumbilicus, Iskin, Ipulsation
Auscultation: IBowel Isounds I(4 Iquadrants), Ivascular Isounds I(bruit)
Percussion: ITone I(4 Iquadrants), I*Ascites(fluid Iin Ithe Iabdomen, Ibecomes Iprotuberant) Iflip Ipt Ito
Ileft-have Itympana Ion Iright Idull Ion Ileft Iand Ivice Iversa Iassessment I(p. I553). I–want Itympana Idue
Ito Igas
, Palpation: ILight Iand Ideep Ipalpation.
Special Iprocedures:
Rebound Itenderness I(Blumberg Iat IMcBurney’s Ipoint) Iand IIliopsoas ISign-appendix, IMurphy’s
ISign-gallbladder
Illeocecal Ivalve IRLQ I–watery
Terms Ito Iknow…
▪ Rectus IDiastasis-separation Iof Ithe Irectus Imuscles Imidline. Ikeep Iabdominal Icontents Iin
Iplace, Ipregnant Iwomen, Ibody Ibuilders, Iabd. ISurgery.
▪ Cullen’s ISign-blue Iring Iaround Iumbilicus, Iinternal Ibleeding
▪ Borborygmi-really Iloud Ibowl Isounds, Ihungry, Inegative Isound Iwhen Iauscultating
▪ Paralytic IIleus-and Inot Iwalking. IBowel Iobstruction.
▪ Melena-Blood Iin Istool, Ioxidized Iblood. IBlack Itarry Ithick Istools
▪ Shifting IDullness- Iascites Ipatients
▪ Distended/Distention-gas, Iascites
▪ Guarding Iof Ithe IAbdomen-Involuntary Iand Ivoluntary
▪ What Iis Iinvolved Iin Ithe Iongoing Iassessment Iof Ia Iclient Iwith Ian ING Itube Ito Isuction I. I. I.?
IWHY I. I. I.? I–Drainage, Iaspirate Igastric Icontents Ievery Itime Ibefore Iyou Iinsert Ianything,
Iturn Ioff Isuction Icontainer Iwhen Ilistening Ito Ibowel Isounds
Nursing IDiagnoses
▪ Ineffective INutrition: Iless Ithan Ibody Irequirements Ir/t Inausea Iand Ivomiting
▪ Constipation Ir/t Idecreased Ifluid I& Ifiber Iintake, Ibed Irest, Imedications
▪ Risk Ifor Iineffective Ihealth Imaintenance Ir/t Ilack Iof Iknowledge Iof Ineed Ifor Irecommended
Icolon Iscreenings
▪ Pain, Iacute Ir/t Iinflammatory Iprocess
What IPredicts IWhat??
▪ Hemoglobin I6.8
▪ Burning ISensation Iin Iepigastric Iregion
▪ No IAppetite
▪ Nausea/Vomiting
Test Iyour Iknowledge
A Iclient Ireports Iabd. Ipain. IHow Ishould Ithe Inurse Iproceed Iwith Ithe Iassessment?
1. Deep Ipalpation
2. Assessing Ithe Ipainful Iarea Ifirst
3. Assessing Ithe Ipainful Iarea Ilast Iwith Ilight Ipalpation
4. Checking Ifor Iwarmth Iat Ithe Ipainful Iarea
When Iauscultating Ia Iclients Iabd. Ithe Inurse Idetects Igurgles Iover Ithe IRLQ. IWhat Ishould Ithe Inurse
Isuspect?
1. Decreased Ibowel Imotility
Chapter I21 IAbdomen
Structure Iand IFunction IAbdominal IOrgans
▪ Solid IViscera-doesn’t Ichange Ishape, Iliver, Ispleen, Iovary
▪ Hollow IViscera-changes Ishape, Istomach, Iintestine, Ibladder
▪ Abdominal IMuscles
▪ Peritoneal ICavity-lines Ithe Iabdomen
Visceral IPeritoneum-lines Iorgans, Istressed Iand Iinflamed Iwith Iappendicitis IandIcholeycistytis
Parietal IPeritoneum-entire Iwall
Structure Iand IFunction IAbdominal IVasculature
▪ Abdominal IAorta-listen Ifor Ibruit Ifor Iaortic Ianeurysm. ICaused Iby Ipressure
▪ Renal IArteries-stenosis Ifrom Iplaque
Subjective IData
▪ Appetite/wt. Ichange
▪ Dysphagia
▪ Abdominal IPain
▪ Nausea/Vomiting
▪ Indigestion
▪ Bowel IHabits
▪ Stool IAssessment
▪ Meds
▪ Nutrition
▪ Social IHx/Alcohol
▪ Past IAbdominal IHx
▪ Stress
▪ Family IHx
Lifespan IConsiderations
▪ Infants I& IChildren: IFeeding I& Ieating Ihabits, IGI Ifunction I& Inervous Isystem Imaturation
Ir/t Itoilet Itraining
▪ Pregnant IFemale: INausea, Iconstipation, Iheartburn I(pyrosis), ILinea INigra
▪ Older IAdult: IMuscle Itone, Iconstipation, Idecreased Iperistaltic Iactivity
Objective IData IAbdomen
Inspection: IContour, Isymmetry, Iumbilicus, Iskin, Ipulsation
Auscultation: IBowel Isounds I(4 Iquadrants), Ivascular Isounds I(bruit)
Percussion: ITone I(4 Iquadrants), I*Ascites(fluid Iin Ithe Iabdomen, Ibecomes Iprotuberant) Iflip Ipt Ito
Ileft-have Itympana Ion Iright Idull Ion Ileft Iand Ivice Iversa Iassessment I(p. I553). I–want Itympana Idue
Ito Igas
, Palpation: ILight Iand Ideep Ipalpation.
Special Iprocedures:
Rebound Itenderness I(Blumberg Iat IMcBurney’s Ipoint) Iand IIliopsoas ISign-appendix, IMurphy’s
ISign-gallbladder
Illeocecal Ivalve IRLQ I–watery
Terms Ito Iknow…
▪ Rectus IDiastasis-separation Iof Ithe Irectus Imuscles Imidline. Ikeep Iabdominal Icontents Iin
Iplace, Ipregnant Iwomen, Ibody Ibuilders, Iabd. ISurgery.
▪ Cullen’s ISign-blue Iring Iaround Iumbilicus, Iinternal Ibleeding
▪ Borborygmi-really Iloud Ibowl Isounds, Ihungry, Inegative Isound Iwhen Iauscultating
▪ Paralytic IIleus-and Inot Iwalking. IBowel Iobstruction.
▪ Melena-Blood Iin Istool, Ioxidized Iblood. IBlack Itarry Ithick Istools
▪ Shifting IDullness- Iascites Ipatients
▪ Distended/Distention-gas, Iascites
▪ Guarding Iof Ithe IAbdomen-Involuntary Iand Ivoluntary
▪ What Iis Iinvolved Iin Ithe Iongoing Iassessment Iof Ia Iclient Iwith Ian ING Itube Ito Isuction I. I. I.?
IWHY I. I. I.? I–Drainage, Iaspirate Igastric Icontents Ievery Itime Ibefore Iyou Iinsert Ianything,
Iturn Ioff Isuction Icontainer Iwhen Ilistening Ito Ibowel Isounds
Nursing IDiagnoses
▪ Ineffective INutrition: Iless Ithan Ibody Irequirements Ir/t Inausea Iand Ivomiting
▪ Constipation Ir/t Idecreased Ifluid I& Ifiber Iintake, Ibed Irest, Imedications
▪ Risk Ifor Iineffective Ihealth Imaintenance Ir/t Ilack Iof Iknowledge Iof Ineed Ifor Irecommended
Icolon Iscreenings
▪ Pain, Iacute Ir/t Iinflammatory Iprocess
What IPredicts IWhat??
▪ Hemoglobin I6.8
▪ Burning ISensation Iin Iepigastric Iregion
▪ No IAppetite
▪ Nausea/Vomiting
Test Iyour Iknowledge
A Iclient Ireports Iabd. Ipain. IHow Ishould Ithe Inurse Iproceed Iwith Ithe Iassessment?
1. Deep Ipalpation
2. Assessing Ithe Ipainful Iarea Ifirst
3. Assessing Ithe Ipainful Iarea Ilast Iwith Ilight Ipalpation
4. Checking Ifor Iwarmth Iat Ithe Ipainful Iarea
When Iauscultating Ia Iclients Iabd. Ithe Inurse Idetects Igurgles Iover Ithe IRLQ. IWhat Ishould Ithe Inurse
Isuspect?
1. Decreased Ibowel Imotility
