locations and assessment techniques

mapping

mapping

the process of dividing the abdomen into quadrants or 9 regions for the purpose of exam reference points

organs of the right upper quadrant

Liver and gallbladder

organs of the left upper quadrant

stomach and spleen

organ in the lower right quadrant

appendix

lower left quadrant pain

is commonly associated with diverticular diseases

dullness sounds are heard

on percussion of the liver

the starting point of auscultation of the abdomen

lower right quadrant

• where sounds are usually present

  • starting point of the large intestine

best position when assessing the abdomen for bladder distention

supine with a small pillow under the head

technique used to assess for bladder distention

indirect percussion

abdominal contour seen in a slightly skinny person

flat

abdominal contour seen on a very skinny person

scaphoid

abdominal contour of a fat person

rounded to protuberant

abdominal contour of an infant

rounded to protuberant

abdominal contour of a person with ascites

protuberant

abdominal contour of a pregnant person in the 3rd trimester

protuberant

nurse should suspect _____ in a client with a hematoma or bluish discoloration in the CVA due to multiple injuries

kidney injury

technique used to assess CVA tenderness

blunt percussion

pain or discomfort during blunt percussion indicates

kidney diseases

kidney are rarely palpable except in the presence of

• cancer

• neoplasm

• polycystic disease

Mcburney’s point

pain at this point indicates acute appendicitis

location of mcburney’s point

draw an imaginary line from umbilicus down and then divide the right side into 3rds

-middle 3rd is the mcburney’s point

positive Blumberg’s sign

is a medical emergency

• stabbing pain when abdomen is compressed and returns to Non compressed stage

• due to peritonea irritation

positive Murphey’s sign

sharp pain at the upper right quadrant when palpating the lower border of the liver

• sign of cholecystitis

positive Rovsing’s sign

pain at the right lower quadrant when palpating the left lower quadrant

• indication of acute appedicitis

positive psoas sign

pain at the right lower quadrant

• patient is placed in supine position with small pillow under the head while legs are up with resistance

• positive for appendicitis

positive cullen’s sign

ecchymosis, bruising, or bluish discoloration of the skin at the periumbilical area

• indicates abdominal bleeding or ruptured ectopic emergency

labs to order when client has acute kidney injury

BUN

when an elderly client complains of onset of urinary incontinence

the nurse should suspect the client has cystitis

wilms tumor

malignancy of the kidneys in infants

• stop palpation when mass is palpated in the abdomen

• palpation of the abdomen will disseminate seed into the abdomen

cigar shaped mass palpated at the left lower quadrant

is a sign of constipation

umbilical hernia in children

• common up to age 5

• if not resolved by age 5, then surgery is indicated

normal bowel signs per min

• 5-30x/min

• irregular high pitched gurgling

borborygmi

• normal when you haven’t eaten in 5-7 hrs

• abnormal when accompanied with s/s of abdominal bleeding or inflammatory bowel disease

strong abdominal pulsation

must be reported ASAP

• could be from triple A (abdominal aortic anuerysm)

kidneys are located

at the CVA

best position to assess for distended bladder

supine with a small pillow behind the head

assessment technique for distended bladder

indirect percussion

risk factors for PUD

• smoking

• NSAIDs

• stress

• positive for h. pylori

• alcohol

assessment for appendicitis

• psoas signs

• rovsing signs

causes of urinary stones

• bladder inflammation

• UTI

• radiation therapy

• inability to empty bladder completely

• when urine is completely saturated with salt, calcium, urea, and uric acid