Focused Abdominal and Physical Systems Assessment Study Guide

Initial Preparation and Patient Identification Procedures

• Infection Control: The clinical encounter begins with the clinician performing hand hygiene by washing their hands.
• Patient Privacy: The clinician explicitly provides privacy for the patient before commencing the assessment.
• Identifying Information: The student/clinician must verify the patient’s identity by asking for:
  • Patient Name.
  • Date of Birth.
• Allergy Assessment: The patient is asked specifically if they have any allergies to medications.

Mental Status and Neurological Orientation Assessment

• Patient Questions: The clinician asks if the patient has any initial questions before the exam starts.
• Level of Consciousness: The patient is noted to be verbal and alert.
• Orientation (A&O x3): The assessment includes evaluating orientation to:
  • Time: Verified by asking for today's date.
  • Place: Verified as part of the alert status.
  • Person: Verified by the patient's identity and awareness of public figures.
• Cognitive and Situational Awareness: The patient is asked to identify external facts to confirm alertness, specifically:
  • "Who's the president of The United States?"

Physical Stature, Mobility, and Posture Observation

• Postural Observation: The clinician observes the patient's posture for specific abnormalities or restrictions, specifically checking for:
  • No constriction.
  • No "lordiosis" (Lordosis).
• Emotional Status: The clinician inquires about the patient's current mood, asking if they are feeling:
  • Sad.
  • Happy.
  • Depressed.
• Ambulation and Gait: The patient is requested to walk to the scale to facilitate measurement as the clinician observes the gait for:
  • Evidence of limping.
  • Use of any other assistive devices.
• Anthropometric Measurements: The patient is brought to the scale to obtain their height and weight.

Clinical Vital Signs and Baseline Data

• Pain Assessment: The clinician asks the patient if they are currently experiencing any pain.
• Baseline Vital Ranges:
  • Pulse: Normal range is defined as $60 \text{ to } 100\,\text{beats per minute}$.
  • Blood Pressure: Normal blood pressure is identified as $120/80$.
  • Temperature: Normal range is defined as $97 \text{ to } 99$.
  • Respiration: Normal "respite respiratory" rate is identified as $12 \text{ to } 20\,\text{beats per minute}$.

Subjective Gastrointestinal History and Visual Inspection

• Chief Complaint: The clinician specifically asks if the patient is experiencing any abdominal pain.
• Bowel History: An interview regarding bowel habits is conducted, including:
  • Frequency of bowel movements (e.g., "Are you going every day?").
  • Consistency of the stool.
• Visual Abdominal Inspection: The clinician requests to pull up the patient's shirt to observe the abdomen. Key observations include:
  • Observation of both sides of the abdomen.
  • Checking for the presence of any hernias.
  • Checking for the presence of any noted lesions.

Abdominal Auscultation: Techniques and Findings

• Equipment: The clinician uses the diaphragm of the stethoscope for listening to bowel sounds.
• Sequence of Auscultation: The clinician listens in the four quadrants in the following order:
  • 1. Right lower quadrant (RLQ).
  • 2. Right upper quadrant (RUQ).
  • 3. Left upper quadrant (LUQ).
  • 4. Left lower quadrant (LLQ).
• Bowel Sound Frequency Classifications:
  • Normal Bowel Sounds: Defined as $5 \text{ to } 30$ sounds.
  • Hypoactive Bowel Sounds: Defined as less than five ($< 5$).
  • Hyperactive Bowel Sounds: Defined as more than thirty ($> 30$).
• Vascular Auscultation: The clinician listens in the middle of the abdomen over the aortic vessel to assess for vascular sounds.
  • Abnormal Sounds: The clinician listens specifically for a "brewing" (bruit) sound or a swishing sound.
  • Findings: The transcript notes no "brewing" sounds or abnormal findings were identified.

Abdominal Palpation and Percussion

• Palpation: The clinician performs palpation across the quadrants (noted as right lower, right upper, and right lower again in the transcript sequence) to check for:
  • Masses.
  • Hernias.
• Percussion: The clinician percusses the abdomen in the following sequence:
  • 1. Right lower quadrant.
  • 2. Right upper quadrant.
  • 3. Left upper quadrant.
  • 4. Left lower quadrant.

Costovertebral Angle (CVA) Assessment

• Positioning: The patient is asked to turn around.
• Technique: The clinician performs a percussion technique on the back (kidney area) on both sides. This is described as hitting the back on both sides to check for tenderness.