Lymphatic
The primary function of the lymphatic system.
What is fluid balance and immune defense?
lymphatics retrieve excess fluid from tissue spaces and returns it to the blood stream and forms a major part of the immune system that defends the body against diseases
The nurse would ask this to assess bowel elimination patterns.
What is "How often do you have a bowel movement?"
understand what is normal to the patient adn if anything has changed
This assessment technique should be performed directly after inspection of the abdomen.
What is auscultation?
this is unique to the abdomen because palpation or any touching can cause stuff to move around and give you false readings
Urine containing blood is referred to as this.
What is hematuria?
hemat= blood
uria= urine
This finding may indicate an upper GI bleed.
What is black, tarry stool?
when the blood has had time to clot and hemolyze it creates the black tarry color if the blood was bright red that indicates a lower GI bleed
The role of lymph nodes in the lymphatic system.
What is filter lymph and trap pathogens?
the nodes filter the fluid before returning to bloodstream getting rid of microorganisms that could be harmful, lymphocytes are the ones that eliminate pathogens
Pregnant clients and clients with GERD experience this frequently.
What is heartburn/pyrosis?
ask how often/when it happens and any associations
The area of the abdomen you palpate last.
What is a tender area/tenderness?
you need to ask the patient before you touch them if they are tender to assess that part last if ticklish with the sandwich method
Painful urination may be a sign of this, along with cloudy urine.
What is a urinary tract infection?
need to treat asap because can turn into pyelonephritis
A nurse notices a patient's abdomen is filled with fluid. This finding is called ________.
What is ascites?
usually associated with liver cirrhosis, can perform a fluid wave and see the fluid move from one side to another
This finding may indicate lymphatic obstruction.
What is lymphedema?
when there's no drainage from the lymphatics the fluid builds up in the interstitial spaces producing edema
Name three factors that can contribute to constipation.
What are fiber, fluids, and medications?
want to be sure they are intaking enough fiber/fluids throughout the day to produce stool, understand what kind of medications they are on and if they should be on a stool softener (like with iron pills)
The two things the nurse inspects for while inspecting the abdomen.
What are color and contour?
contour (flat, rounded, scaphoid, protuberant), color/skin(jaundice, erythema, cullens, grey tuners, scars, striae, spider angiomas) also look at the umbilicus for location
Before an abdominal assessment, a patient should have a __________ bladder.
What is empty?
need an empty bladder for an accurate examination
A nurse hears loud, frequent gurgling without even using their stethoscope. They would record these bowel sounds as__________.
What is hyperactive?
borborygmi can be heard as well can indicate gastroenteritis
How pitting edema is graded during an assessment.
What is measuring depth and duration of indentation after pressure?
to assess if there is pitting press your finger down into the extremity watching for any indention when you pick your finger up
Vomiting blood is referred to as __________.
What is hematemesis?
hemat=blood
emesis=vomit
The normal contour for an abdominal assessment.
What is flat?
scaphoid would be skinny can be considered malnourished, rounded would be pregnant women, young children, obese adults with poor muscle tone
A person would have pain in this area from urinary tract infections and kidney stones.
What is flank pain?
rebound tenderness would be indication of appendicitis and referred pain is pain in a different location from the involved organ , murphy's sign is indication of cholecystitis
The nurse inspects the abdomen and notices a large bruise covering the umbilicus and surrounding area.This is called _________.
What is cullen's sign?
Cullen's is when there is ecchymosis around the the umbilicus, grey tuner's would be the bruising on the side of abdomen
A nurse presses on a patient’s lower leg and observes a 6 mm indentation that lasts more than 30 seconds. This would be graded as_______.
What is 3+ pitting edema?
when grading you measure on a 0-4+ scale 0=none 1+=mild 2mm, 2+=moderate 4mm, 3+= moderately severe 6mm, 4+= severe 8mm
These lifestyle modifications can improve GI function.
What are smoking cessation and limiting alcohol consumption?
need to ask your patient on their habits regarding these to educate on the importance to limit
The nurse must wait for __________ for each quadrant they record "absent bowel sounds" for.
What is five minutes?
bowel sounds CAN NOT be documented as absent without listening for a full 5 min could indicate an obstruction
This finding may indicate poor renal function and fluid retention.
What is jugular vein distention?
the retained fluid causes the pressure to increase in the veins causing a visible bulging of the jugular vein can also indicate heart failure
The seven reasons for a rounded or protuberant abdomen contour.
What are fat, fibroids, flatus, fetus, fluid, feces, and fatal tumor?
always think of the 7 F's if not flat, and determine what is the cause