Health Assessment Exam 2

What should you ask when obtaining present medical history of the abdomen?

Do you have any chronic conditions that affect the GI system such as diabetes, hepatitis, or cirrhosis?

What should you ask regarding abdominal distention?

Have you noticed any abdominal distention? If yes, how long has it been distended? What makes it better or worse?

What questions should be asked about digestion problems?

Have you had any problems with the digestion process, such as heartburn, indigestion, nausea, or vomiting? If yes, what makes the symptoms better or worse?

What should you inquire about traveling or exposure to diseases?

Have you been traveling? Have you been exposed to infectious disease or unsanitary water or food preparation?

What details should be gathered for vomiting?

For vomiting, describe the color texture and whether it contains blood or undigested food particles.

What should you ask regarding the color and consistency of the stool?

Describe the color and consistency of the stool.

What should you ask about changes in appetite?

Have you noticed any changes in your appetite? If yes, have you noticed any changes in your weight? Can you describe what you ate in the last 24 hours?

What is the order the abdomen should be assessed?

Inspect, Ausculatate, Palpate

How should the client be positioned when their abdomen is about to be assessed?

Supine with their head on a pillow and knees slightly bent to help the muscles relax

True or False: The genital and thoracic area should be covered for privacy and comfort when assessing the abdomen?

True

Skin tone an appearance findings when assessing the abdomen?

Abdominal skin should be smooth and dry. Even in tone or lighter than the client’s sun exposed areas

Expected variations of the skin when assessing the abdomen?

Moles, healed scars, and striae. Ask the client about their origin. Document locations, measurement, and characteristics

Unexpected skin findings when assessing the abdomen?

Lesions, bruising, dilated veins, purple striae, rashes, jaundice

Expected findings for abdominal symmetry

Symmetry of abdominal movement associated with breathing without any bulges or masses

Unexpected findings for abdominal symmetry

Localized bulging, visible mass, or asymmetry of movement and visible intense pulsations

Expected finding of the umbilicus

Inverted and abdominal midline

True or False: When auscultating the abdomen, start in the lower right quadrant at the ileocecal valve with a gentle touch and proceed in a clockwise direction?

True

How many bowel sounds should be heard when auscultating the abdomen?

5 and 34 times per minute

Borborygmus bowel sounds

Hyperactive, rumbling or growling sound that may be heard with or without a stethoscope

Hyperactive bowel sounds

Louder and more intense than expected because of increased motility or peristalsis, possibly due to diarrhea

Hypoactive bowel sounds

Diminished, soft sounds that occur less than one minute and may also be related to impaired mobility. This may be due to medications, anesthesia, constipation, or bowel obstruction

Absent bowel sounds may be related to what?

Intestinal obstruction

What should the nurse do if a patient’s bowel sounds are absent?

Listen for 5 minutes in each quadrant to determine absence

Vascular or swishing sounds in the bowel may suggest what?

Blood vessel of liver disorder

What must a nurse NOT do is vascular or swishing sounds are heard in the bowel?

Do not Palpate

Should a nurse palpate painful areas of the abdomen first or last?

Last

How can you palpate a patient’s abdomen if they are ticklish?

Put their hand under your hand

Unexpected findings when palpating the abdomen?

Tenderness, masses, involuntary rigidity or muscle guarding

Bristol Stool Chart: Type 1

Separate, hard lumps

Bristol Stool Chart: Type 2

Solid, lumpy

Bristol Stool Chart: Type 3

Solid, smooth with cracks

Bristol Stool Chart: Type 4

Soft, snake like

Bristol Stool Chart: Type 5

Soft blobs, clear edges

Bristol Stool Chart: Type 6

Mushy Fluffy Pieces

Bristol Stool Chart: Type 7

Watery, no solid pieces

Rate this on the bristol stool chart

Type 1

Rate this on the bristol stool chart

Type 2

Rate this on the bristol stool chart

Type 3

Rate this on the bristol stool chart

Type 4

Rate this on the bristol stool chart

Type 5

Rate this on the bristol stool chart

Type 6

Rate this on the bristol stool chart

Type 7

Rebound tenderness “Blumberg’s Sign”

Nurse palpates the abdomen away from the source of the pain

Rebound tenderness may be a sign of…?

Appendicitis or peritonitis

McBurney’s Point

1/3 the distance from the umbilicus to the right iliac crest

Pain at McBurney’s point may indicate…?

Appendicitis

Murphy’s Sign

Nurse pushes on the right costal margin and asks the patient to inhale

Pain from a positive Murphy’s Sign may indicate…?

Possible Cholecystitis

Costovertebral Angle Tenderness

The nurse places one hand over the costovertebral angle and gently strikes the hand with the ulnar side of the closed fist of the other hand

A positive Cosotovertebral Angle Tenderness may indicate…?

Kidney inflammation or infection

What places paitents at risk for GI conditions like constipation?

Sedentary lifestyle

Health promotion of the abdomen with testing

CDC recommends regular screenings over the age of 45 years

What is the formula to calculate the number of pack years a person has smoked?

Packs per day * # of years smoked

If a patient smoked 2 packs of cigs a day for the last 30 years, what is their total pack-years?

60 Pack-Years

Eupnea

12-20 breaths per minute

Bradypnea

<12 breaths per minute

Tachypnea

>20 breaths per minute

What is the optimal position for breathing?

Tripod position

If a patient is anxious of confused, it could be a sign of…?

Acute hypoxia

Signs of respiratory distress

Tachypnea, Sweating, Tachycardia, Tripod position, Intercostal muscle retractions

Signs of Respiratroy Arrest

Not breathing

Assessment of chronic hypoxia may show…?

Barrel Chest, Clubbed Fingers, lower Sp02

Where should you assess breath sounds?

In the intercostal spaces

To determine equal expansion of the lungs, where should you place your fingers?

T9 or T10

Hypoventilation

Shallow breaths that may be irregular

Hyperventilation

Deep breathing that is often rapid

Cheyne-Stokes Breathing

Breathing patterns of cycles that begin with rapid, shallow breaths, increase to deep breaths, ending with periods of apnea

Ataxic Breathing

Very irregular with varying depths of respiration and periods of apnea

Tracheal Breath Sounds

High ptich, very loud and harsh

Where are tracheal breath sounds heard?

Over the trachea

Bronchial Breath Sounds

Relatively loud, high pitch

Where are bronchial breath sounds heard?

Around the trachea and larynx

Bronchovesicular Breath Sounds

Intermediate sound level and reside over sternum and upper vertebra

Vesicular breath sounds

Heard over majority of the peripheral lungs and are soft intensity and lower pitch

Stridor

High pitch crowing sound. Upper airway obstruction or foreign body

Pleural Friction Rub

Low pitch, coarse, grating sound, may indicate pleural inflammation

Crackles

Crackling, Grating, Popping, Bubbling

True or False: Crackles are not cleared by a cough

True

Wheeze

High-pitch whistling sound through narrowed passages

Rhonchi

Low pitched, snoring sound. Fluid, mucus, or growth

Where do you listen for the aortic valve?

2nd ICS right of the sternal border

Where do you listen for the pulmonic valve?

2nd ICS left of the sternal boarder

Where do you listen for the Erbs Point?

3rd ICS left of the sternal border

Where do you listen for the Tricuspid Valve?

4th ICS left of the sternal boarder

Point of maximal impulse

Left MCL 4th to 5th ICS

S1

Lub, dull, low pitched sound

S2

Dub, Higher pitched sound

Systole

Silent period between S1 and S2

Diastole

Silent period between S2 and the next S1

S3 or S4 may indicate what?

Presence of heart disease

True or False: S3 in an adolescent is NOT a normal finding?

False

A lack of hair or thicky shiny skin or the presence of ulcers may indicate what?

Decreased circulation

Lordosis is most common in which population?

Obese, pregnant, and toddlers

Kyphosis is most common in which population?

Older Adults

Which neruological structure is most important for maintaining balance or coordination

Cerebellum

What type of footwear should someone with a high fall risk use when walking on carpet?

Leather footwear

Stereognosis test

Ask the patient to close their eyes while you place a common, small object in their hand

Graphesthesia test

Measures brain ability to recognize letters or numbers drawn on your skin using only the sensation of touch

Two-point discrimination test

Neurological assessment that measures tactile spatial acuity and nerve density

Dysethesia

Neurological condition cuasing abnormal, unpleasant sensations like burning, tingling, or eletric shocks, that occur without an obvious trigger or in response to a mild touch