Abdominal and Nutritional Assessment

ausculation

listening to sounds within body using a stethoscope

Body mass index

a screening tool used to measure body weight relative to height

Borborygmi

loud, gurgling bowel sounds signaling increased GI motility and are often due to inflammation, anxiety, diarrhea, bleeding and reactions to specific foods

bowel sounds

any normal gurgling or rumbling noises caused by the movement of fluid and gas through intestines during digestion.

dysphagia

Difficulty swallowing often caused by food or liquid getting stuck on its way to the stomach

distention

An abnormal or excessive swelling of a body part or organ

hyperactive bowel sounds

loud, high-pitched, rushing, tinkling sounds that signal increased motility caused by moving food, fluid and gas

hypoactive bowel sounds

Diminished or absent bowel sounds signal decreased motility that can naturally occur during sleep due to slowed intestinal activity

-ABSENCE OF BOWEL SOUNDS FOR 5 MINS

Ileus

Obstruction of the intestine, often caused by failure of peristalsis

-Normal peristalsis is stopped due to any surgery that involves the bowel, typically only lasts 24 to 48 hours

inspection

General observation of the patient as a whole, progressing to specific body areas

-noticing emotional, mental, and physical components of a patient

percussion

tapping on a surface to determine the difference in the density of the underlying structure

Peristalsis

wave-like muscle contractions that move contents through the small and large intestines

Striae

stretch marks that can be observed on the skin

What assessment should be completed after a patient return from surgery

The nurse should assess the normal return of bowel function along with the patients ability to swallow safely. This confirms that peristalsis is returning and the patient is not at risk for choking

signs and symptoms of dysphagia

-Coughing or gagging while eating

-Choking

-Aspiration

-Drooling

-Pockets of food retained in the mouth

-Gargly sounding voice

-Sensation of food getting stuck in the throat

symptoms include pain or discomfort when swallowing along with a sensation that food is stuck in the throat. Dysphagia commonly leads to malnutrition

10 physical signs of alternations of nutritional status

tired appearance, overweight, underweight, impaired mobility, confused mental status, anorexia, indigestion, abdominal swelling, elevated blood pressure and deep red oral mucous

order of an abdominal assessment

inspection, auscultation, percussion, palpation

what are the concerns for a patient with abdominal distention

intestinal gas, a tumor or fluid in the abdominal cavity

when would it be important to remove palpation from the physical assessment

over a surgical incision over tender organs or abdonminal masses

when would hypoactive bowel sound be normal

normal after surgery following general anesthesia or during deep sleep

formula for BMI

weight (kg) / height (m^2)

Underweight BMI

less than 18.5

normal BMI

18.5-24.9

Obese BMI

over 30

morbidly obese BMI

greater than 40

how many ml is 1 tsp

5 mL

how many mls is 1 T

15

1 ounce tsp and T

2 T and 6 tsp

1 ounce in mls

30 mls

1 Cup in ounces

8 ounces

1 cup in mls

240 mL

1 pt is how many cups

2 cups

1 pint is how many ounces

16

1 pt is how many mls

480mls

1 qt is how many pts

2 pts

1 qt is how many cups

4 cups

1 qt is how many ounces

32 oz

1 qt is how many mls

960mls

1 gallon is how many qts

4 qts

1 gallon is how many cups

16 cups

1 gallon is how many ounces

128 ounces

1 gallon is how many mls

3785 mls

Tympany

high-pitched, musical, drumlike percussion note heard when percussing over the stomach and intestine

-INDICATES A HALLOW, AIR FILLED STRUCTURE LIKE INTESTINES