N232 Abdominal/Nutrition Lecture

Abdominal Hollow Organs

• stomach

• small intestine

• colon

• bladder

• gallbladder

abdominal solid organs

• liver

• kidneys

• pancreas

• spleen

• ovaries

abdominal blood vessels

• aorta

• right and left iliac

• renal

• femoral

abdominal quadrants

RUQ, RLQ, LUQ, LLQ

Abdominal WDL

• abdomen soft, nondistended

• no nausea, vomiting, diarrhea, constipation

Abdominal history

• surgery

• medications (GI upset: common side effect)

• disorders/disease

  • peptic ulcer disease

  • gallbladder disease

  • gastroesophageal reflux disease

  • hepatitis/cirrhosis

  • hernia

  • renal disease/renal calculi

  • irritable/inflammatory bowel disease

abdominal symptoms

• pain

• fever/chills

• nausea/vomiting

• diarrhea/constipation/last BM

• melena (dark feces/blood - color shows how far up in GI tract the bleed is)

• dysphagia (difficulty swallowing)

• appetite changes

• food intolerances

• 24hr diet recall; 3 day food diary

• recent weight loss (could indicate smth other than GI if more than 10 lbs in last 2 months without trying)

• ask about GU issues

abdominal history - social factors

• alcohol intake/tobacco use/drug use

• recent camping/travel

• work, home, daycare environment

• medications

• family history

• family remedies

abdominal exam pearls

• empty bladder (ask when they last peed)

• relax abdominal muscles (take pillow, place under knees, put feet of bed up)

• full expose abdomen, drape as necessary (lower pants to bottom of abdomen)

• warm hands + stethoscope

• short fingernails

• monitor facial expressions, esp in children (look for grimace, guarding)

• visualize internal organs as you examine

exam order

1. inspection

2. auscultation

3. percussion (we don’t do)

4. palpation (light + deep)

inspection

• general appearance

• color

• contour (flat, rounded, protuberant, scaphoid)

• position of umbilicus

• observe for symmetry, bulging, masses

• surface motion (peristalsis)

• lesions/scars or markings

flat stomach

straight horizontal line observed from costal margin to symphysis pubis (WDL, common in thin person)

rounded abdomen

sometimes called convex; horizontal line curves outwards, showing increase in abdominal fat/decrease in muscle tone; contour is considered normal variation in toddler + pregnant female

protuberant abdomen

(local protuberance - just one/two quadrants) similar to rounded, only greater; contour is anticipated in pregnancy; also seen in the adult with obesity, ascites, other conditions

scaphoid abdomen

sometimes called concave abdomen; horizontal line curves inward toward vertebral column, giving abdomen sunken appearance; seen in very thin person

ascites

fluid in abdomen from liver failure (distended, whole abdomen, treatment is pericentesis)

see fluid, tympany, dullness, umbilicus may protrude

abdominal tumor

• tympany

• dullness

• localized

  • protuberant

obesity vs distended

obesity = skin/adipose tissue folds over, stomach shifts upon standing

distension = one structure, stomach is skin tight, does not move upon standing

pediatric inspection

• umbilical location

• umbilical hernia/bulging (can be displaced bc of hernia)

• diastasis recti

diastasis recti

rectus abdominis muscles separation; in newborns/pregnant women

auscultation

*done before palpation!

• bowel sounds: borborygmus

  • listen in all 4 quadrants for a full minute (should hear 5-30 bowel sounds)

  • no noise = medical emergency

  • if no noise suspected, listen for 5 minutes/quadrant

• vascular sounds/blood vessels (aorta, renals, iliacs, femorals)

• friction rubs

palpation

• masses, tenderness, pulsation

• observe for guarding

• organ location, size, contour

• light palpation (first) → 1-2 cm

• deep palpation (second) → 5-8cm (couple inches)

• specific organ palpation

palpation when patient has kidney transplant

old kidney can be near the surface - feel it (expected, not WDL)

abdominal testing

certain exams/maneuvers performed to determine cause of abdominal pain

• murphy’s sign - cholecystitis

• psoas test - peritoneal irritation

• rovsing’s sign - peritoneal irritation/appendicitis

• obturators sign - general peritoneal irritation

abdominal pain (types/causes)

types:

• parietal (aka somatic; irritation to parietal peritoneal wall)

• referred (touch one thing, feel pain somewhere else)

• visceral (source organ)

causes:

• inflammation

• distension

• ischemia

what and how to assess first?

key word: prioritization

1. get baseline assessment

2. focus on eliminating or confirming the most serious or deadly conditions that fit the clinical presentation (those need interventions fastest)

3. third, assess for most likely culprits (think horse first, no zebra)

peritoneal irritation/peritonitis

• localized or general irritation of peritoneal membrane (not in one quadrant/shows systemic)

• likely causes: infectious process, organ damage, internal bleeding/trauma

• assessment might show: abdominal pain, tenderness, bloating, nausea, vomiting, decreased urine output, fever

• gushy stuff should stay in gushy places! (if not = medical emergency)

abdominal pain - ominous symptoms

• severe/explosive pain with sudden onset

• continuous, progressive (worsening, not cyclical)

• awakens from sleep/affects activity level

• accompanied by lightheadedness/fainting (blood in wrong place)

• stabbing/tearing sensation

abdominal pain - pearls

• pain is sudden, severe, progressive, lasts more than 6 hours = requires surgical intervention

• in general, farther from umbilicus the pain localizes = greater chance that a surgical condition exists

• left shoulder pain - pancreatitis?

• obstipation (non-passage of both stool + gas) suggests a surgical condition

things we HAVE to know

• digestive system/organs + order of food passage

• landmarks (which organ in which quadrants?)

• hernias! (ventral, umbilical, inguinal, hiatal)

stomach lab values

H. Pylori (normal = negative)

liver lab values

• ALT

• AST

• ALP

• LDH

• Hepatic antigens

• Serum vit B12

• Serum total bilirubin

• Serum ammonia

• Serum albumin

pancreas lab values

• amylase

• lipase

• glucose

• calcium

abdominal diagnostic testing

• abdominal x-ray, CT, and/or MRI

• barium swallow

• colonoscopy

• esophagoscopy

• upper endoscopy

• fecal occult blood testing

• gallbladder ultrasound

• gastric analysis

• gastroscopy

• liver, kidney, stomach biopsies

• endoscopic retrograde cholangiography (ECP)

• percutaneous transhepatic cholangiography (PTCA) (imaging of gallbladder through skin over liver)

ABD

abdomen/abdominal

GIB

gastrointestinal bleeed

AC

before meals (usually in AC/HS blood sugar checks)

NG

nasogastric (as in the tube)

BM

bowel movement

NPO

nothing by mouth

PO

by mouth

N/V

nausea + vomiting

TPN

total parenteral nutrition (all given through IV, NPO)

NANDAs

• imbalanced nutrition

• pain, acute, chronic

• risk for aspiration

• nausea

• diarrhea

• dysfunctional GI mobility

• risk for delayed surgical recovery

• disturbed body image

• readiness for enhanced knowledge

healthy diet guidelines

• follow healthy dietary pattern at every life stage

• customize and enjoy nutrient-dense food and beverage choices to reflect personal preferences, cultural traditions, and budgetary considerations

• focus on meeting food group needs with nutrient-dense foods and beverages and stay within calorie limits

• limit foods and beverages high in added sugars, sat fats, and sodium, and limit alc beverages

dietary guidelines for americans 2020-2025

• emphasize fruits, veggies, whole grains, and fat-free or low fat milk and milk products

• includes lean meats: poultry, fish, and lean beef, beans, eggs and nuts

• is low in sat fats, trans fats, cholesterol, salt, and added sugars

MyPlate

• fruits

• grains

• veggies

• protein

• dairy

circumstances that increase need for calories

• higher levels of physical activity

• recovery from illness/injury

• stress

• puberty

• growth spurts

• pregnancy

average caloric need for 19-30 male

2400 calories

average caloric need for 19-30 female

2000 calories

carbs

body’s main energy source; found in legumes, grains, vegetables, fruits, sugars, baked, etc

total fat

helps absorb essential vitamins and nutrients, keeps us warm, and keeps are immune system working

sodium

helps maintain fluid balance, affects nerve impulses, influences contraction/relaxation of muscles; found in table salt, processed food, etc

fiber

part of plant-based foods, helps to improve blood sugars, promote GI motility, and lower cholesterol; found in vegetables, fruits, oats, bran, whole grains, etc

protein

essential for growth and development, and repair of body tissues; found in meats, beans, eggs, nuts, etc