METHODICAL INSTRUCTION FOR STUDENTS OF THE RN-BSN PROGRAM 1 COURSE
Nursing Faculty
LESSON № 28 (PRACTICAL – 6 HOURS)
Theme 1: Abdomen: Disorders.
Aim: To be able to perform a complete assessment of the abdomen and to describe common variations (health alterations) that may be found on examination of the abdomen.
Professional orientation of students: The abdominal assessment provides information about a variety of systems because every system, with the exception of the respiratory system, is found within the abdomen. The stomach, small and large intestines, liver, gallbladder, pancreas, spleen, kidneys, ureters, bladder, aortic vasculature, spine, uterus and ovaries, or spermatic cord are all located in the abdomen. Not only does assessment of the abdomen enable you to obtain valuable information about the functioning of the gastrointestinal (GI), cardiovascular, reproductive, neuromuscular, and genitourinary systems; it can also provide vital information about the health status of every other system.
Methodology of Practical Class. (9.00-12.00)
Algorithm of students’ communication with patients with pathology in subject (communication skills) (for clinical department):
During examination of the patient students have to use such communicative algorithm:
Complaints and anamnesis taking in patients
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Take complaints and anamnesis in a patient.
5. Explain to the patient results of his/her lab tests correctly and accessibly.
6. Explain to the patient your actions concerning him/her (the necessity of hospitalization, certain examinations and manipulations), which are planned in future.
7. Conversation accomplishment.
Objective examination:
Physical methods of examination of patients with internal diseases
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to a patient, what examinations will be carried out and get his/her informed consent.
5. Find a contact with the patient and make an attempt to gain his/her trust.
6. Inform about the possibility of appearing of unpleasant feelings during the examination.
7. Prepare for the examination (clean warm hands, cut nails, warm phonendoscope, etc.).
8. Examination (demonstration of clinical skill).
9. Explain to the patient results of his/her lab tests correctly and accessibly.
10. Conversation accomplishment.
Estimation of laboratory and instrumental investigations
Informing about the results of examination of patients with internal diseases
1. Friendly facial expression and smile.
2. Gentle tone of speech.
3. Greeting and introducing.
4. Explain to a patient results of his/her lab tests correctly and clearly.
5. Involve the patient into the conversation (compare present examination results with previous ones, clarify whether your explanations are clearly understood).
Planning and prognosis the results of the conservative treatment
Friendly facial expression and smile.
1. Gentle tone of speech.
2. Greeting and introducing.
3. Correct and clear explanation of necessary treatment directions.
4. Discuss with a patient the peculiarities of taking medicines, duration of their usage, possible side effects; find out whether your explanations are clear for him/her or not.
5. Conversation accomplishment.
Work 1. . Abdomen
1.Structure and function of internal abdominal anatomy
2.Surface landmarks
3.Know the location of abdominal organs
4.Discriminate normal bowel sounds
Work 2. Understand the rationale and methods of examination of the abdomen
1.Subjective data
2.Inspection of the abdomen
3.Auscultation of abdomen
4.Percussion of abdomen
5.Palpation of abdomen
6.Developmental considerations
Work 3. Accurately record the assessment
Be able to perform a complete assessment of the abdomen
I. Health History
A. Current Status
1. Describe chief complaint
2. Pain
3. Ability to walk upright
4. Nutritional Assessment
a. 24 hour recall
b. Food preferences and dislikes
c. Cultural and religious values
d. Access to food
e. Eating behaviors
f. Appetite changes
5. Indigestion
a. Fullness
b. Heartburn
c. Discomfort
d. Excessive belching
e. Flatulence
f. Loss of appetite
g. Pain
6. Heartburn - usually substernal
a. Body positions
b. Food irritants
c. Time of day
7. Nausea
8. Vomiting
a. Appearance of emesis/odor
b. Hematemesis
9. Stool
a. Diarrhea - watery or loose stool
b. Tenesmus - cramping pain with strained, ineffectual evacuation
c. Steatorrhea - frothy, greasy, and foul-smelling stool w/undigested fat
d. Melaena - black, tarry stool
e. Bloody red stool
f. Occult blood
g. Constipation
h. Ability to pass flatus
10. Alcohol intake
11. Fever
12. Difficulty breathing
13. Swelling of lymph nodes in neck, axilla, and groin
B. Past Health Status
1. Have you had any problems with your mouth, throat, abdomen, or rectum that have lasted for a long time?
2. Have you had any nerve problems, such as weakness or numbness in your hands and fingers?
3. Have you ever had surgery on your mouth, throat, abdomen, or rectum?
4. Do you have any allergies such as to milk products?
5. Do you use laxatives or enemas? If so, how often?
6. Do you take any prescription or over-the-counter medications? If so, which drugs and at what dosages?
C. Family Health Status
1. Has anyone in your family had colorectal cancer or polyps?
2. Has anyone in your family had colitis?
II. Physical Examination of the Abdomen
A. General Approach
1. Patient must be warm and relaxed.
2. Good lighting.
3. Full exposure of abdomen from xyphoid process to groin.
4. Patient should not have full bladder.
5. Position in supine position with pillow under head and knees.
6. Arms should be held across chest or be at sides.
7. Have warm hands and a warm stethoscope.
8. Avoid quick, unexpected movements.
9. Distract the patient with questions.
10. Monitor your examination by watching patient's face.
B. Inspection of the Abdomen
1. Contour and Symmetry
a. Flat
b. Scaphoid - seen in school-aged children and wasting diseases
c. Round - pot belly; normal in infants and toddlers
d. Protuberant
e. Distended
2. Scars
a. Location
b. Length
c. Color
3. Striae - prolonged stretching of the skin; seen in ascites, obesity, tumor, pregnancy, and Cushing's Syndrome
a. Color: white/silver red/pink/blue purple
4. Rashes and Lesions
a. Spider nevi (cutaneous angiomas)
5. Umbilicus
a. Contour
b. Location
c. Signs of hernia - lifting head or coughing - considered normal in white skinned children until age 2 and in black skinned children until age 7
d. Cullen's sign - bluish discoloration - suggests intraperitoneal hemorrhage
6. Enlarged organs
a. Assess during deep breath
b. Differentiate between masses in the abdominal wall and intra-abdominal masses by having patient voluntarily tense abdominal muscles.
7. Masses - note size and location during deep inspiration
8. Peristalsis
a. Thin individuals
b. Intestinal obstruction
9. Dilated veins - seen with increased collateral circulation
10. Distribution of Pubic Hair (Escutcheon)
a. Female distribution - triangle with base above the symphysis
b. Male distribution - diamond with upper vertex extending as high as the umbilicus
11. Turner's sign - blue discoloration of the flanks - indicates gastrointestinal hemorrhage. There is extravasation of blood from intra-abdominal organs to extraperitoneal sites (for example, hemorrhagic pancreatitis).
C. Auscultation of the Abdomen
You must auscultate before you percuss or palpate abdomen because these maneuvers may alter the frequency of bowel sounds. Enhanced peristaltic sounds may mask other abnormal abdominal sounds such as bruits and friction rubs.
1. Bowel sounds - listen and note frequency and character (normal sounds consist of clicks and gurgles and occur 5 to 34 per minute).
a. Frequency
b. Intensity
c. Location
d. Pitch
e. Pattern
1. Absence of bowel sound - established only after 5 minutes of continuous listening. Caused by an immobile bowel of adynamic ileus (peritonitis, severe hypokalemia, complete obstruction, paralytic ileus, gangrene). A full bladder can obscure sounds.
2. Sluggish (hypoactive) bowel sounds - 3 to 5 per minute; seen with decreased bowel motility.
3. Hyperactive bowel sounds - short but frequent peristaltic sounds. greater than 34 sounds per minute. Caused by anxiety, infectious diarrhea, irritation of intestinal mucosa from blood, or gastroenteritis.
4. High-pitched tinkling sounds and rushes - hyperperistalsis also occurs during intestinal obstruction as the intestine tries to push contents through obstructed area. Usually accompanied by cramping pain.
5. Borborygmi
2. Vascular Sounds
a. Auscultation of Bruits
|
Location |
Indication |
|
Over abdominal aorta |
Atherosclerosis Aneurysm Aortic compression by a tumor |
|
Renal arteries |
Renal artery stenosis (check for hypertension) |
|
Right upper quadrant |
Vascular tumor of the liver (Hepatoma, Hemangioma) |
|
Iliac arteries |
Atherosclerosis |
|
Femoral arteries |
Atherosclerosis |
b. Auscultation of Friction Rubs - grating sounds that are heard in association with respirations as roughened serous membranes rub over each other.
c. Venous Hum - auscultate over epigastric and umbilical area. Listen for a soft low pitched continuous sound. Occurs over areas with increased collateral circulation between portal and systemic venous systems.
D. Percussion of the Abdomen
Percussion of the abdomen helps assess for intestinal distention, free fluid, solid masses, hepatomegaly, and splenomegaly. It is contraindicated in clients with AAA and organ transplants.
1. Percuss in all 9 sections to assess for tympany and dullness
a. Tympany - children's abdomens are usually more tympanic than adults (swallowed air)
b. Dullness
2. Assess for gastric tympany
3. Assess for liver dullness
4. Assess for suprapubic dullness
5. Assess for splenic dullness
a. 10th ICS posterior to mid-axillary line
6. Percuss the lower and upper border of the liver at the midclavicular and midsternal lines
a. Normal limits: 6-12 cm at midclavicular line
4.4-8.2 cm at midsternal line
Children: 5 yrs - 7 cm
12 yrs - 9 cm
b. Hepatic enlargement suggests:
1. Downward displacement of the liver by emphysematous lung
2. Mass adjacent to the liver
3. Hepatitis
c. Absence of liver dullness suggests:
1. Perforation of hollow intestinal organ/air in abdominal cavity
2. Small, atrophic cirrhotic liver
7. Percuss the flanks for shifting dullness
a. Ascites
E. Palpation of the abdomen
1. Light Palpation - use a light, gently dipping motion to palpate for superficial organs, masses, areas of tenderness, and increased resistance (1-2 cm)
a. Normal consistency
b. Guarding
c. Tenderness
d. Special considerations
1. Ticklishness
2. Flex knees
3. Palpate areas of tenderness last
2. Deep Palpation - 2-handed technique - hand moves with expiration and rests with inspiration (4 cm)
a. Masses (neoplasms, cysts, aneurysms, feces in bowel)
b. Tenderness
c. Rigidity
1. Voluntary tightening - fear or nervousness
2. Involuntary rigidity - inflammation of the peritoneum
3. Assessing Abdominal Pain
a. Visceral pain - arises from within the abdominal organ. dull pain, poorly localized (intestinal obstruction, pancreatic tumor)
b. Parietal (somatic) pain - caused by inflammation of structure that is innervated by a somatic sensory nerve. Pain is sharp and well localized (peritonitis, ruptured appendix)
c. McBurney Point - a point of specialized tenderness in acute appendicitis between the umbilicus and the right anterior superior iliac spine. Appendicitis pain starts in the umbilical area and progresses down to the right lower quadrant.
4. Rebound Tenderness - occurs when parietal peritoneum becomes inflamed
a. Press over region far away from the tender area and release pressure suddenly. Pain will occur in area of disease.
b. Apply gentle pressure over tender area and have patient cough.
5. Palpation for Splenic Enlargement - seen in hyperplasia, congestion, neoplasms, fatty infiltration, systemic infections, and chronic anemia.
a. Stand at patient's right
b. Place a supporting left hand under patient's left costovertebral angle and exert pressure to push spleen anteriorly
c. At the same time, slide the fingers of your right hand gently upward beneath the patient's left anterior costal margin
d. Ask patient to take a deep breath
e. A palpable spleen is always considered enlarged. A spleen must be enlarged 3-5 times in order to be palpable.
f. If you suspect the spleen is enlarged but you cannot feel it while patient is in the supine position, repeat the procedure while the patient is in the right lateral decubitus position.
6. Palpate over the suprapubic region for a large distended bladder. A bladder can distend as far as the umbilicus.
7. Palpate for Hepatic Enlargement
Palpate the Liver - support posterior 11th and 12th rib, gently pressing upward with left hand. Place right hand to the side of the rectus muscle and press upward. Ask the patient to take a deep breath and feel the lower border of the descending liver as it strikes the fingertips. A hooking technique may also be used.
a. A palpable liver may be caused by:
1. Abnormally large liver (neoplasms, hepatitis, early cirrhosis)
2. A liver that is pushed downward by a low diaphragm
3. A congenitally large right lobe
4. Frequently palpable in children under age of 4 years
b. Describe edge of the liver:
1. Nodular - neoplasm
2. Soft - very hard liver indicated cirrhosis
3. Smooth - normal
4. Tender - inflammation of the liver
8. Palpation for aortic aneurysms
a. In a thin individual the normal aorta may be felt as a pulsatile structure midline in the abdomen
b. In an aneurysm the aorta is a sausage-like enlargement that has a strong pulsation and is expansible. The pulsations will displace the examining fingers laterally. Also pain in the abdomen or back may be present.
9. Vertebral tenderness - palpate with one finger into the soft tissues of the costovertebral angle (between the spine and the 12th rib). Tenderness on palpation suggests inflammation of the kidney.
10. Palpation of the kidneys
a. Place one hand posteriorly beneath the costal margin and press directly upward.
b. Palpate the kidney by pressing deeply below the costal margin at the midclavicular line as the patient takes a deep breath. You can try to capture the kidney between your 2 hands.
c. Palpate the right kidney while standing on patient's right side and palpate left kidney by standing on the patient's left side.
d. Palpation of kidneys is similar to palpating the liver and spleen except the hand is pressed more deeply into the abdomen. A right kidney may be palpable. A normal left kidney is rarely palpable.
e. Renal enlargement occurs in infection, tumor, and polycystic kidneys.
f. Contraindication to palpating kidneys
1. Renal Transplant Patients
2. Embryoma (Wilm's Tumor) - a malignant tumor in young children (seeding of a tumor).
11. Palpation of inguinal and femoral lymph nodes. Found above and below inguinal ligament. The inguinal lymph nodes are frequently enlarged from superficial infections of toes and feet. They are also enlarged in systematic viral infections, fungal parasitic or protozoal infections or in lymphoma or leukemia.
12. Palpation of femoral pulses. Also look for femoral hernia (more common in women).
13. Fluid Wave Test in Ascites
a. Use 2 people for this test. Assistant will place hand midline down abdomen.
b. Tap one flank and feel opposite flank for a delayed impulse transmitted throughout the fluid. Seen with greater than 500cc of ascitic fluid.
14. Hepatojugular reflux
This is an early sign of venous constriction that occurs before increase in venous pressure is demonstrable by other means.
a. Lower the patient's head until the venous pulsation in jugular vein is just visible above the clavicles.
b. Remind the patient to breathe at a normal rate and depth.
c. Place hand in right upper quadrant of the abdomen and press firmly upward under the costal margin.
d. If venous constriction is present, displacement of this small amount of blood from the liver will cause a visible rise in the column of blood in the jugular veins. Seen in early CHF and cardiac tamponade.
15. Special Maneuvers
Seminar discussion of theoretical issues. (12.00-14.00)
Individual Students Program.
Test evaluation and situational tasks. (14.15.-15.00)
1. Parasympathetic stimulation of the gastrointestinal tract
|
a. |
Increases motor and secretory activity and relaxation of sphincters. |
|
b. |
Maintains the tone of smooth muscles to stimulate movement. |
|
c. |
Slows movement, inhibits secretion and contracts sphincters. |
|
d. |
Decreases blood supplied to the gastrointestinal tract. |
____ 2. Which problem should the nurse anticipate in the client undergoing radiation for cancer of the oral cavity?
|
a. |
The client will fail to absorb most nutrients. |
|
b. |
The client will be able to digest carbohydrates but not proteins. |
|
c. |
The client will have an impairment in the softening and breaking down of food. |
|
d. |
The client will have difficulty propelling food from the mouth to the esophagus. |
____ 3. A client with damage to cranial nerve X describes difficulty in moving food toward the rear of the mouth for swallowing. With which phase of swallowing is this client experiencing difficulty?
|
a. |
Esophageal |
|
b. |
Pharyngeal |
|
c. |
Propulsant |
|
d. |
Voluntary |
____ 4. What alteration in function can be expected if parietal cells of the stomach become impaired?
|
a. |
Gastric motility will be decreased. |
|
b. |
Secretion of gastrin will be increased. |
|
c. |
Secretion of pepsinogen will be increased. |
|
d. |
Absorption of vitamin B12 will be decreased. |
____ 5. A client has developed diabetes mellitus type 1 and no longer produces insulin. What cells of the pancreas have become dysfunctional?
|
a. |
Beta cells |
|
b. |
Alpha cells |
|
c. |
Acinar cells |
|
d. |
Kupffer cells |
____ 6. What is the role of the liver in response to increased energy requirements?
|
a. |
Storage of fatty acids and triglycerides |
|
b. |
Activation of Kupffer cells |
|
c. |
Storage and release of glycogen |
|
d. |
Removal of ammonia |
____ 7. What statement regarding changes to the gastric mucosa in an older adult is true?
|
a. |
Peristalsis decreases and nerve impulses are dulled. |
|
b. |
Atrophy of gastric mucosa results in hypochlorhydria. |
|
c. |
Lipase production is decreased. |
|
d. |
Protein synthesis is decreased. |
____ 8. Which of the following questions would be appropriate to ask the client in order to collect data concerning the Nutritional-Metabolic Pattern, according to Gordon’s Functional Health Patterns?
|
a. |
“Have you noticed a change in the amount of urine passed?” |
|
b. |
“Have you experienced any recent changes in weight?” |
|
c. |
“What is your usual bowel elimination pattern?” |
|
d. |
“When was your last rectal examination?” |
____ 9. What question should the nurse ask to obtain information as to the origin of acute diarrhea times 4 days?
|
a. |
“Have you traveled out of the country recently?” |
|
b. |
“Are you taking any anti-inflammatory drugs?” |
|
c. |
“Have you had a colonoscopy recently?” |
|
d. |
“Do you have trouble swallowing?” |
____ 10. During an initial assessment, a client with gastrointestinal problems reports the use of nonsteroidal anti-inflammatory drugs (NSAIDs) three times a day for arthritis pain. What would be the nurse’s best response?
|
a. |
“NSAIDs are not helpful for arthritis pain.” |
|
b. |
“NSAIDs should be taken only twice daily.” |
|
c. |
“NSAIDs can interfere with the absorption of nutrients.” |
|
d. |
“NSAIDs can result in ulcers or bleeding.” 1. ANS: |
Initial level of knowledge and skills are checked by solving situational tasks for each topic, answers in test evaluations and constructive questions.
(the instructor has tests & situational tasks)
Student should know:
1. Anatomy and physiology of the abdomen and gastrointestinal system.
2. Describe questions and related rationale used to obtain health history data about the abdomen and gastrointestinal system.
3. Identify equipment appropriate to the examination of the abdomen and gastrointestinal system.
4. Describe preparatory guidelines relative to assessment of the abdomen.
5. The techniques of inspection, auscultation, palpation, and percussion as used in the assessment of the abdomen.
Student should be able to:
1. Identify health history questions for assessment of abdomen.
2. Demonstrate health assessment of the abdomen.
3. Differentiate between normal and abnormal abdominal assessment findings.
4. Identify health promotion needs of clients based on findings of the abdominal assessment.
5. Describe common variations (health alterations) that may be found on examination of the abdomen.
Correct answers of test evaluations and situational tasks:
1. ANS: A
Parasympathetic stimulation of the GI tract is provided by the vagus nerve causing increases in motor and secretory activity and relaxation of sphincters.
2. ANS: C
Saliva is responsible for the softening of food in the mouth and contains an enzyme (ptyalin) that assists in the breakdown of carbohydrates.
3. ANS: D
The movement of the tongue forcing food towards the pharynx is called the voluntary phase of swallowing. Paralysis of cranial nerve X would impede this function.
4. ANS: D
Parietal cells of the stomach secrete hydrochloric acid and produce intrinsic factor, which aids in the absorption of vitamin B12.
5. ANS: A
The endocrine part of the pancreas is composed of the islets of Langerhans, with alpha cells producing glucagon and beta cells producing insulin.
6. ANS: C
The liver’s role in carbohydrate metabolism involves the storage and release of glycogen as energy requirements change. An increase in energy requirements results in the release of glycogen.
7. ANS: B
In older adults, the gastric mucosa atrophies. There is a decrease in the number of gastrin-secreting cells, which leads to hypochlorhydria.
8. ANS: B
Data about changes in weight, food intake, and difficulties chewing or swallowing are reflective of the Nutritional-Metabolic Pattern. All other choices reflect questions posed to collect data concerning the Elimination Pattern.
9. ANS: A
A history of travel may help pinpoint an infectious source of symptoms such as diarrhea.
10. ANS: D
Long-term use of NSAIDs for chronic pain can precipitate peptic ulcer formation through the inhibition of prostaglandins.
References:
Jarvis, C. (2011). Physical examination and health assessment. (6th ed.). Philadelphia: W.B. Saunders
В – Additional:
Weber, J. & Kelley, J., (2010). Health assessment in nursing. (4th Ed.). Lippincott ISBN: 978-0-781-78160-2
Weber, J. & Kelley, J., (2010). Health assessment in nursing lab manual. (4th Ed.). Lippincott ISBN: 978-0-781-78161-9
Mosby’s Dictionary of Medicine, Nursing, and Health Professions,
(2009). (8th ed.) St. Louis: Elsevier ISBN: 9780323052900
Venes, D. editor (2009) Taber’s Cyclopedia Medical Dictionary (21th ed.). Philadelphia: F.A. Davis. ISBN: 9780803615595
Methodical instruction has been worked out by: O. Krekhovska-Lepyavko MD, BSN, MSN
Methodical instruction was discussed and adapted at the Department sitting
June 12, 2013. Minute № 13