Maryville AHA NURS 612 Exam 3 | STUDY GUIDE
Terms in this set (105)
○ Abdominal pain-OLDCARTS
○ When did the pain start?
○ Where is the pain in your stomach?
○ Does the pain radiate to other locations?
HPI questions for chief complaint of
○ Have experience nausea/vomiting, indigestion or increase in belching.
abdominal issue
○ What medications have you used to treat your symptoms?
○ Have you had any diarrhea or constipation?
○ Do you have to use laxative frequently?
○ What is your regular dietary habits?
-Abdominal contour
-Symmetry
-Umbilicus
-Skin Color
-Vascularity
-Scars
inspection of abdomen -Striae
-Lesions or rashes
-Abdominal movement when breathing
-Aortic pulsation
-Have patient raise head while laying down and look for masses
hernia or muscle separation
inspection, auscultation, percussion, palpation
Abdominal assessment order
Always auscultate prior to percussion and palpation as it can change sound.
, Bowel sounds in all four quadrants- note frequency and
character listen for friction rubs over liver and
spleen
listen for bruits over the aortic, renal, illiac and femoral arteries
Abdomen Auscultation
listen for venous hum around epigastric area above the belly button
○ Bruits- A swishing sound heard over the aortic, renal iliac,
and femoral arteries, indicating narrowing or aneurysm.
○ Pop/Tinkles- High pitch sound suggesting intestinal fluid and
air under pressure, as in early obstruction.
○ Rushes- Rushes of high-pitched sounds that coincide with
cramping suggests intestinal obstruction.
○ Borborygmi- Increased prolonged gurgles occur with
gastroenteritis, early intestinal obstruction, and hunger.
○ Rubs- Grating sounds that vary with respiration. Indicate
inflammation of the peritoneal surface of an organ from
Abdominal findings abdomen
tumor, infection, or splenic infarct.
○ Venous Hum- A soft humming noise often heard in hepatic
cirrhosis that is caused by increased collateral circulation
between portal and systemic venous system.
○ Succussion splash- A splashing noise produced by shaking the
body when there is both gas and fluid in a cavity or free air in
the peritoneum or thorax.
○ Decreased/absent bowel sounds- Occurs with peritonitis or paralytic ileus.
o First, determine the lower border of the liver by percussing
up from an area of tympany along the right midclavicular line.
Mark the point where tympany changes to dullness, which
usually occurs at or slightly below the costal margin.
o Second, determine the upper border of the liver by percussing
How to percuss to estimate the liver down from an area of resonance along the right midclavicular
span line. Mark the point where resonance changes to dullness,
, which usually is in the fifth intercostal space.
o Third, measure the distance between the marks. The vertical
liver span usually ranges from 6 to 12 cm.
Blumberg Sign Rebound tenderness, RLQ, appendicitis, peritoneal irritation
ecchymosis around umbilicus
Cullen sign
-hemoperitoneum, pancreatitis, ectopic pregnancy
Dance sign Absence of bowel sounds, RLQ, intussusception, bowel obstruction
Ecchymosis of the flanks. Possible rupture of the spleen.
Grey Turner's sign
Hemoperitoneum, pancreatitis, pain may radiate to the left
shoulder
Abdominal pain radiated to the left shoulder, splenic rupture, renal
Kehr's sign
calculi, ectopic pregnancy
Tests for peritoneal irritation, appendicitis, jarring to the body. Stand
Markle Sign (heel jar)
with straight legs, then stand on your toes, then relax. Positive if
this causes pain.
McBurney's sign rebound tenderness to the epigastric area associated with appendicitis
Terms in this set (105)
○ Abdominal pain-OLDCARTS
○ When did the pain start?
○ Where is the pain in your stomach?
○ Does the pain radiate to other locations?
HPI questions for chief complaint of
○ Have experience nausea/vomiting, indigestion or increase in belching.
abdominal issue
○ What medications have you used to treat your symptoms?
○ Have you had any diarrhea or constipation?
○ Do you have to use laxative frequently?
○ What is your regular dietary habits?
-Abdominal contour
-Symmetry
-Umbilicus
-Skin Color
-Vascularity
-Scars
inspection of abdomen -Striae
-Lesions or rashes
-Abdominal movement when breathing
-Aortic pulsation
-Have patient raise head while laying down and look for masses
hernia or muscle separation
inspection, auscultation, percussion, palpation
Abdominal assessment order
Always auscultate prior to percussion and palpation as it can change sound.
, Bowel sounds in all four quadrants- note frequency and
character listen for friction rubs over liver and
spleen
listen for bruits over the aortic, renal, illiac and femoral arteries
Abdomen Auscultation
listen for venous hum around epigastric area above the belly button
○ Bruits- A swishing sound heard over the aortic, renal iliac,
and femoral arteries, indicating narrowing or aneurysm.
○ Pop/Tinkles- High pitch sound suggesting intestinal fluid and
air under pressure, as in early obstruction.
○ Rushes- Rushes of high-pitched sounds that coincide with
cramping suggests intestinal obstruction.
○ Borborygmi- Increased prolonged gurgles occur with
gastroenteritis, early intestinal obstruction, and hunger.
○ Rubs- Grating sounds that vary with respiration. Indicate
inflammation of the peritoneal surface of an organ from
Abdominal findings abdomen
tumor, infection, or splenic infarct.
○ Venous Hum- A soft humming noise often heard in hepatic
cirrhosis that is caused by increased collateral circulation
between portal and systemic venous system.
○ Succussion splash- A splashing noise produced by shaking the
body when there is both gas and fluid in a cavity or free air in
the peritoneum or thorax.
○ Decreased/absent bowel sounds- Occurs with peritonitis or paralytic ileus.
o First, determine the lower border of the liver by percussing
up from an area of tympany along the right midclavicular line.
Mark the point where tympany changes to dullness, which
usually occurs at or slightly below the costal margin.
o Second, determine the upper border of the liver by percussing
How to percuss to estimate the liver down from an area of resonance along the right midclavicular
span line. Mark the point where resonance changes to dullness,
, which usually is in the fifth intercostal space.
o Third, measure the distance between the marks. The vertical
liver span usually ranges from 6 to 12 cm.
Blumberg Sign Rebound tenderness, RLQ, appendicitis, peritoneal irritation
ecchymosis around umbilicus
Cullen sign
-hemoperitoneum, pancreatitis, ectopic pregnancy
Dance sign Absence of bowel sounds, RLQ, intussusception, bowel obstruction
Ecchymosis of the flanks. Possible rupture of the spleen.
Grey Turner's sign
Hemoperitoneum, pancreatitis, pain may radiate to the left
shoulder
Abdominal pain radiated to the left shoulder, splenic rupture, renal
Kehr's sign
calculi, ectopic pregnancy
Tests for peritoneal irritation, appendicitis, jarring to the body. Stand
Markle Sign (heel jar)
with straight legs, then stand on your toes, then relax. Positive if
this causes pain.
McBurney's sign rebound tenderness to the epigastric area associated with appendicitis
