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Application of Health Assessment NUR 225 Module Seven Physical

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Application of Health Assessment NUR 225 Module Seven Physical King Saud University Collage of Nursing Medical Surgical Nursing depart Application of Health Assessment NUR 225 Module Seven Physical examination of gastrointestinal and urinary system 1 Gastrointestinal & Urinary examination 1- Obtain health history related to gastrointestinal disorders. 2- In preparation for examination of the abdomen, the patient should: - Ask the client to empty the bladder before beginning the examination to eliminate bladder distention and interference with an accurate examination . - Instruct the client to remove clothes and to put on a gown . - Help the client to lie supine with the arms folded across the chest or resting by the sides . ( Raising arms above the head or folding them behind the head will tense the abdominal muscles ). - A flat pillow may be placed under the client’s head for comfort. - Slightly flex the client’s legs by placing a pillow or rolled blanket under the client’s knees to help relax the abdominal muscles. - Drape the client with sheets so that the abdomen is visible from the lower rib cage to the pubic area. - Instruct the client to breathe through the mouth and to take slow, deep breaths. This promotes relaxation. - Before touching the abdomen , ask the client about painful or tender areas. Always assess these areas at the end of the examination . - Watch the patient face for signs of discomfort during the examination . - Perform the examination in the following order inspection, auscultation, percussion, and palpation . - Adjust the bed level as necessary throughout the examination and approach the client from the right side. - Use tangential lighting, if available for optimal visualization of the abdomen . - Warm hands are essential for the abdominal examination. ( Cold hands cause the client to tense the abdominal muscles ) 2 3- Abdominal Quadrants : - The abdomen can be described as having four quadrants: the right upper quadrant ( RUQ ) , right lower quadrant ( RLQ ) , Left lower quadrant ( LLQ) and left upper quadrant ( LUQ ) . - Another method divides the abdomen into nine regions : epigastric, umbilical, and hypogastric or suprapubic . 4- Prepare equipment Needed : - Small pillow or rolled blanket - Centimeter ruler - Stethoscope (warm the diaphragm and bell) - Marking pen 3 Technique Normal findings Abnormal findings A-Inspection - Observe the coloration of the Abdominal skin may be paler Purple discoloration at the skin. than the general skin tone. flanks indicates bleeding ,within the abdominal wall possibly from trauma to the kidneys, pancreas, or duodenum or from pancreatitis. The yellow hue of jaundice may be more apparent on the abdomen. Pale , Redness may indicate inflammation & Bruises . - Note the vascularity of the Scattered fine veins may be Dilated veins may be seen abdominal skin visible . with cirrhosis of the liver, obstruction of the inferior vena cava, portal hypertension, or ascites - Note any striae (stretch New striae are pink or bluish in Dark bluish-pink striae are marks) . color , old striae are silvery, associated with Cushing’s white, linear and uneven stretch syndrome . marks from past pregnancies or weight gain -Assess for lesions and rashes . Abdomen is free of lesions or Changes in moles including rashes flat or raised brown size, color, and border moles, however , are normal and symmetry . may be apparent Bleeding moles or petechiae (reddish or purple lesions) may also be abnormal . - Inspect the umbilicus note Umbilical skin tones are similar Cullen’s sign: A bluish or color , location & contour. to surrounding abdominal skin purple discoloration around tones or even pinkish . the umbilicus (periumbilical ecchymosis) indicates intra-abdominal bleeding. Location : In midline a lateral A deviated umbilicus may line. be caused by pressure from a mass, enlarged organs, hernia, fluid, or scar tissue. Contour : inverted or protruding An everted umbilicus is no more than 0.5 cm and is round seen with abdominal . distention , An enlarged everte umbilicus suggests umbilical hernia. 4 - Inspect abdominal contour. Abdomen is flat, rounded, or Sitting at the client’s side, look scaphoid A generalized protuberant or across the abdomen at a distended abdomen may be level slightly higher than the due to obesity, air (gas), or client’s abdomen. fluid accumulation. - Observe aortic pulsations A slight pulsation of the Vigorous, wide, exaggerated abdominal aorta, which is visible pulsations may be seen with in the epigastrium, extends full abdominal aortic aneurysm. length in thin people . - Observe for peristaltic Normally, peristaltic waves are Peristaltic waves are waves . not seen, although they may be increased and progress in a visible in very thin people as ripple-like fashion from the slight ripples on the abdominal LUQ to the RLQ with wall. intestinal obstruction. B- Auscultation Auscultate for bowel sounds. - A series of intermittent, soft - "Hyperactive" bowel Use the diaphragm of the clicks and gurgles are heard at a sounds that are rushing, stethoscope and make sure rate of 5 – 30 per minute. tinkling and high pitched that it is warm before you may be abnormal indicating place it on the client’s very rapid motility heard in abdomen. Apply light pressure early bowel obstruction or simply rest the stethoscope gastroenteritis, diarrhea, or on a tender with use of laxatives. abdomen. Begin in the RLQ - "Hypoactive" bowel and proceed clockwise, sounds indicate diminished covering all quadrants . bowel motility. Common causes include paralytic - Listen for at least 5 minutes ileus following abdominal before determining that no surgery. bowel sounds are present and - Decreased or absent bowel that the bowels are silent sounds signify the absence CLINICAL TIP: of bowel motility. Bowel sounds may be more active in the RLQ . 5 - Confirm bowel sounds in each quadrant . Listen for up to 5 minutes (minimum of 1 minute per quadrant) to confirm the absence of bowel sounds . CLINICAL TIP : Bowel sounds normally occur every 5 to 15 seconds. - Note the intensity, pitch, and frequency of the sounds . - Auscultate for vascular sounds: Use the bell of the stethoscope Bruits are not normally heard A bruit that indicate an (low- to listen for bruits over abdominal aorta or renal, aneurysm or renal arterial pitched, murmur-like sound, iliac, or femoral arteries . stenosis pronounced BROO-ee) over the abdominal aorta and renal, iliac, and femoral arteries . - Listen for venous hum: Using the bell of the Venous hum is not normally venous hum heard in the stethoscope, listen for a heard over the epigastric and epigastric or umbilical. venous hum in the epigastric umbilical areas . and umbilical areas. 6 C- Percussion 1- Percuss the abdomen for Generalized tympany Accentuated tympany or tones . predominates over the abdomen hyperresonance is heard - Lightly and systematically because of air in the stomach and over a gaseous distended percuss all quadrants. intestines. Dullness is heard over abdomen . the liver and spleen . - Abdominal percussion sequences may proceed clockwise or up and down over the abdomen . 2- Percuss the span of the liver by determining its lower and upper borders - To assess the lower border, The lower border of liver begin in the RLQ at the mid- dullness is located at the costal clavicular line (MCL) and margin to 1 to 2 cm below. percuss upward. Note the change from tympany to dullness. Mark this point: It is the lower border of liver dullness . 7 - To assess the upper border, The upper border of liver The upper border of liver percuss over the upper right dullness is located between the dullness may be difficult chest at the MCL and percuss left fifth and seventh intercostal to estimate if obscured by downward, noting the change spaces . pleural fluid of lung from lung resonance to liver consolidation . dullness. Mark this point It is the upper border of liver dullness . - Measure the distance The normal liver span at the Hepatomegaly, a liver span between the two marks, this is MCL is 6- 12 cm (greater in men that exceeds normal limits the span of the liver . and taller clients, less in shorter (enlarged), is characteristic clients ) of liver tumors cirrhosis, abscess, and vascular engorgement . Atrophy of the liver is indicated by a decreased Span . 3- Percuss the spleen. Begin posterior to the The spleen is an oval area of Splenomegaly is left mid-axillary line (MAL), dullness approximately 7 cm characterized by an area of and percuss downward, noting wide near the left tenth rib and dullness greater than 7 cm the change from lung slightly posterior to the MAL . wide. The enlargement may resonance to splenic dullness result from traumatic injury, portal hypertension and mononucleosis . 8 4- Perform blunt percussion on Normally, no tenderness or pain Tenderness or sharp pain the kidneys. is elicited or reported by the elicited over the CVA Placing your left hand flat client. The examiner senses only suggests kidney infection against the costovertebral a dull thud . (pyelonephritis), renal angle over the 12 ribs . Use the calculi or hydronephrosis . ulnar side of your right fist to strike your left hand. 5- Bladder Percussion Ask the patient to empty the You should hear tympanic sound Full bladder produce dull bladder first. sound Place patient in a supine position. Start at the symphysis pubis and percuss upward toward the bladder and over it D- Palpation 1- light palpation : Abdomen is non - tender and soft Involuntary reflex guarding Light palpation is used to There is no guarding. is serious and reflects identify areas of tenderness peritoneal irritation. The and muscular resistance. Using abdomen is rigid . the fingertips, begin palpation in a non-tender quadrant, and compress to a depth of 1 cm in a dipping motion. Then gently lift the fingers and move to the next area . 9 2- Deep palpation : Normal (mild) tenderness is Severe tenderness or pain Deeply palpate all quadrants to possible over the xiphoid, aorta, may be related to trauma, delineate abdominal organs cecum , sigmoid colon, and peritonitis, infection, and detect subtle masses. ovaries with deep palpation .
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