final exam - abdomen, NGs, bowel elimination

Abdominal assessment sequence and documentation

preparation

• supine, knees bent, only expose abdomen, empty bladder

inspection

• shape, pulsation, peristalsis, masses

auscultation

• start RLQ and note location & frequency; work clockwise

palpation

• tender areas last

• light palpation 1-2cm deep

• expect softness & no nodules

• involuntary guarding = muscle spasm

• voluntary guarding = knees up, breathe out to get better exam

expected and unexpected auscultation findings

expected

• normoactive BS: high pitched clicks and gurgles x4 quadrants, 5-35/min

unexpected

• hyperactive: more than 30 sounds/min

• hypoactive: less than 5 sounds/min

Unexpected colors of and types of vomitus and stool

stool

• melena: black, tarry = upper GI bleed

• bright red blood per rectum = lower GI bleed, hemorrhoids

• clay/white = lack of bile, meds

• steatorrhea = fatty stool

vomitus

• hematemesis: coffee grounds, frank blood emesis

• bilious emesis: bright green

hematemesis - “coffee-ground” emesis

blood has been in the stomach long enough to be partially digested by gastric acid

• bleeding is not currently fresh and active, but recent

• upper GI bleed

NG tube insertion

• place client in high-fowler’s

• measure tube from patent nare to ear lobe (on same side) to xiphoid. mark w/ pen/tape

• reassure when pt gags at pharynx. sip

• rotate and advance to help pass through nasopharynx. advance to mark on tube

• s/s of respiratory distress = STOP

• secure to gown. if double-lumen is used, ensure vent above stomach

• aspirate gastric contents pH<5

• x-ray confirmation is gold standard

complications of NG placement

• discomfort

• sinusitis

• nosebleed

• sore throat

• pressure ulcers

• electrolyte imbalance

• stomach-lining irritation

• aspiration pneumonia

The purpose of the use of a nasogastric tube in a patient with a bowel obstruction

decompression of the GI tract

• gas and fluid accumulate in the stomach and intestines. an NG tube removes this buildup by suction

  • reduced abdominal distention, relieves nausea and vomiting, prevents aspiration of stomach contents, reduced pain & discomfort