Assessment Techniques
What is take a deep breath?
Hyperactive bowel sound that is fairly common, can be heard without a stethoscope.
What is borborygmus?
A pulsating, blowing sound of which the nurse notes location, pitch and timing.
What is vascular sounds (bruits)- associated with stenosis or occlusion of an artery?
A burning sensation in the esophagus and stomach.
What is abnormal- pyrosis?
The best/first thing to ask after the patient complains about abdominal pain.
What is location, "Please point to it" ?
The nurse knows to auscultate which quadrant first?
What is Right Lower Quadrant?
Occurs when the person is cold, tense or ticklish.
What is voluntary guarding?
This finding can be related to flatus, fluid, constipation, or intestinal obstruction.
What is abdominal distention?
Upon palpation, you are able to feel the right kidney, lower pole.
What is normal?
When you ask your patient things such as "how do you get your groceries" or "how do you prepare your meals", you are assessing for_______ with what population.
What is risk for nutritional deficit amongst older adults?
When assessing for CVA tenderness, describe what each hand is doing.
What is non dominant hand is open and the palm is resting on the patients skin? (your dominant hand makes a fist and a thud motion to assess for pain.
The xiphoid process, normal liver edge, right kidney (lower pole), pulsatile aorta, rectus muscles (lateral borders) sacral promontory, ascending colon, cecum, sigmoid colon, full bladder.
What are normally palpable structures?
The kind of sounds you would expect to hear after surgery.
What is hypoactive bowel sounds?
Your patient reports severe, sharp, persistent pain and tenderness localized in the McBurney point. Pain is aggravated by movement, coughing and deep breathing. Pt also describes not wanting to eat, nausea, vomiting, and fever
What is appendicitis?
The patient reports prolonged vomiting over the course of a couple days. You will assess the following...
What is skin turgor, urine output, color of urine, mucous membranes, and thirst?
Your patient complains of pain in the right upper quadrant. What follow up questions need to be asked to determine possible abnormal findings?
What is- Does your pain radiate, how long does your pain last, when did you notice your pain started? What makes your pain worse or better? Does is happen before, with, or after meals; does activity or rest affect your pain?
The two things you want to note when auscultating bowel sounds.
What is character and frequency?
A client comes in with a visibly distended abdomen, during percussion you hear mainly this sound.
What is dullness?
Upon inspection, auscultation, palpation and percussion of your patient you find: enlarged abdominal girth, single curve, everted umbilicus, bulging flanks when supine, taught glistening skin, normal bowl sounds over intestines, diminished over bulging flanks, tympany at top where intestines are, fluid wave.
What is abnormal and ascites?
What is something essential you want to ask before you begin the physical assessment of the abdomen?
What is ask the patient to empty their bladder? (saving a urine specimen if needed)
If you want to assess a client for peritonitis you would perform this.
What is Blumberg sign or test for rebound tenderness?
Bowel sounds are expected to be present in the right lower quadrant because this organ is located here.
What is the ileocecal valve?
A protruded, enlarged or extruded umbilicus found in a newborn could be the result of this.
What is umbilical hernia?
When interviewing your patient, the patient discloses stomach pain that is chronic and typically on an empty stomach. Upon further questioning, you find the patient has been using Advil daily for approximately 9 months. The patient most likely experiencing?
What is peptic ulcer disease or gastric ulcer?
During the interview, the client who is 45 says his mother and aunt suffer from IBS, during the health promotion part of the assessment you would want to teach this patient about
What is colon cancer screening?