Abdominal Assessment 1
What are the steps for an abdominal assessment?
Inspect, auscultate, percuss, and palpate
How long do you listen to each quadrant of the abdomen?
15 seconds
How are enteral tubes named?
Based on the location of where it enters the body.
Ex: Nasogastric: tip in the stomach, Nasoduodenal: tip is in the duodenum (first part of the small intestine), Nasojejunal: tip is in the jejunum (second part of the small intestine)
Inserted into the mouth: orogastric, oroduodenal, and orojejunal.
What is dumping syndrome? What are the signs and symptoms?
Rapid feeding causing a distended small intestine and rapid gastric emptying.
Symptoms: Excessive gas, bloating, nausea, diarrhea, cramping, tachycardia, sweating, and dizziness.
What is stomach decompression?
What would be abnormal findings while inspecting the abdomen?
A distended, asymmetrical, abdomen. Also, abdominal hernias, striae, and ascites.
How long do you listen to each quadrant of the abdomen if bowel sounds are absent?
2 minutes per quadrant= 9 minutes total
How long should NG tubes be placed? How long can PEG/PEJ tubes be placed?
NG- Short term (less than 4 weeks)
Gastrostomy/Jejunostomy: Long-term feeding tubes
Gastric Residual Volume
(Facility policy) When you aspirate the gastric contents through the tube look at the residual for aspiration risk. High volume (200mL or more)= higher risk for aspiration.
Hold feedings for residuals of 500mL or more and additional signs of intolerance
Refeed the feedings to the patient after to maintain electrolyte balance. Flush tube to maintain patency.
When should decompression be turned off?
For an abdominal assessment and for 30 minutes after medication administration.
What are the four ways you can describe an abdomens contour?
flat, rounded, scaphoid (sunken in), or protuberant (bulging)
What area of the abdomen should you palpate last? What should you never palpate?
Painful areas last, never palpate over a pulsating midline mass.
Feeding Tubes VS Decompression Tubes
Feeding tubes: Fewer holes at the tip, more flexible and narrower. Placement is assessed every four hours (and before feeding.) Also, check GI intolerance every 4 hours.
Decompression: More holes at the tip, more ridged, and a larger diameter. Placement is assessed every 4-8 hours.
Bolus/Gravity feedings
Bolus feedings via gravity are given using a 60 mL syringe. Flush with 30-50 mL of water or sterile saline after checking residual Height of the syringe controls the rate of administration. If patient has GI distress, lower the height of the syringe to slow the feeding down. Flush the enteral tube with 30-50 mL of water or sterile saline. If unable to flush the tube: reposition client and attempt flush again. Inject 10 to 20 mL of air and aspirate again. If repeated attempts to flush fail consult with primary care provider HOB 30-45 degrees for at minimum for 1 hour after the feedings. Replace disposable items every 24 hours- date and time when supplies are opened.
What are the three types of decompression tubes? Which one(s) can be intermittent suction and which one(s) can be continuous?
Levin: OG or NG. Intermittent suction only. (One lumen)
Cantor: NG tube. Intermittent suction only. (One lumen)
Salem Sump: Most common. OG or NG. Intermittent suction or continuous suction (2 lumens) One lumen decompresses, and the other maintains a continuous airflow to prevent the tube from attaching to the gastric mucosa. An anti-reflux valve prevents gastric secretion from traveling through the wrong lumen.
Always keep blue vent above the waist and open to air
When auscultating the abdomen, what quadrant should you start in?
Right Lower quadrant. Why?
What are the 3 types of bowel sounds that can be heard?
Hypoactive bowel sounds, active bowel sounds, hyperactive bowel sounds.
What are some nursing responsibilities with enteral tubes?
Checking the placement, assessing and cleaning the insertion site (checking for skin breakdown/pain), frequent oral care (every 2-4 hrs), and monitoring for complications. Maintain HOB 30-45 degrees
Pump Feedings. How is it programed? When should you check it? When should items be changed?
The pump is programed in mL/hr. Check the pump every 4-6 hrs for continuous feeding and flush every 4-6 hrs to maintain patency. Check the placement/residual volume every 4-6 hrs (facility policy).
Reusable items should be cleaned every 24 hrs, closed system is good for 48 hours
Feedings into the intestines are always continuous to prevent dumping syndrome
When should we irrigate and flush a decompression tube?
Flush: Every shift
Every 4-8 hrs with 30-60mL of water or sterile saline.
Before, between, and after medication administration
Salem Sump: sump-inject 10-20 mL of air into the blue pigtail valve to re-establish an air buffer
Percussion: What kind of organs will produce dull sounds? What kind will produce tympany or high-pitched sounds?
Solid Organs: Dull Sounds
Hollow Organs: Tympany/High-pitched sounds
The RLQ should be dull, the rest should produce high pitched sounds with percussion
Explain how you would palpate the abdomen
Lightly push down (1cm) into the abdomen. Palpate in a circular motion, starting in the RLQ and moving clockwise ending in the LLQ. You also want to palpate midline above the bladder. If the bladder is palpable, this could indicate urinary retention.
How do you assess the tube placement? What should the gastric content look like? What is the normal gastric pH?
Initial placement should always be verified with an x-ray and the measurement should be marked.
Then measure the external length of the tube, aspirate GI contents and assess appearance and pH value
Gastric Content appearance: Grassy green with particles
pH: less than or equal to 5.5
Dobbhoff, gastrostomy, and jejunostomy. What are these for?
Which has the greatest risk for aspiration? Which has the least? Which has the greatest risk for dumping syndrome?
Dobbhoff- Greatest risk for aspiration (NG tube)
Gastrostomy- Placed through the abdominal wall into the stomach for long-term feeding/medication administration.
Jejunostomy- Placed through the abdominal wall into the jejunum. When patients cannot tolerate feedings in their stomach. Least risk for aspiration (lower in the body), greatest risk for dumping syndrome (less absorption in the intestine)
NG Tube Removal
Complete abdominal assessment, Have patient sitting upright, Check placement, Instill 30-50 mL of air to clear tubing prior to removal, Instruct patient to hold their breath, Remove and coil in hand