Nursing 104

N104: Essentials of Nursing Care – Health Safety Study Guide • Ensure that the examination room is warm, since the patient will be exposed during different parts of the assessment. • Explain each step of the exam: what will happen, why the exam is being done, andhow the patient can help during the exam. • Explain how the results of the exam will be used. • Ask about the presence or history of: o Previous surgeries o Pain including location, onset, description, frequency, any associated symptoms, and relieving or exacerbating factors o Change in appetite or eating habits o Change in weight (gain or loss) o Other signs and symptoms (nausea, vomiting, constipation, diarrhea, heartburn, belching, gas, blood in stools or emesis, difficulty swallowing, etc.) o Food intolerance o Bowel habits • Inspect the abdomen. o Normal: Uniform color; no blemishes or lesions; striae (stretch marks); surgical scars if history of surgery; flat, concave, or slightly rounded; no obvious bulging when patient breathes; symmetrical movement with breathing; visible peristalsis in thin patient o Deviations from normal: Marked differences in color; tense or shiny skin; blemishes or lesions; striae that are purple in color; obviously distended; bulges under the ribcage when patient takes deep breath; asymmetrical movement with breathing; visible peristalsis in heavy patient • Auscultate the abdomen: Use the diaphragm of the stethoscope to listen for bowel sounds in all areas of the abdomen. Use the bell of the stethoscope to listen for bruits over the aortic and renal arteries. Auscultate over the spleen and liver (upper left and upper right under the ribcage) to listen for frictionrubs. o Normal: Audible bowel sounds in all quadrants; absence of bruits and friction rubs o Deviations from normal: Absent (no bowel sounds in several minutes of auscultation), hypoactive (1-2 bowel sounds per minute), or hyperactive (every 3 seconds) bowel sounds in one or more quadrants; bruit over aorta; friction rub over liver or spleen • Percuss the abdomen and liver: Begin in one quadrant and progress through all the areas, assessing for the presence of gas and solid masses or fluids. o Normal: Tympany over the stomach and bowels; dullness over the liver and spleen o Deviations from normal: Large areas of dullness over the stomach or bowels • Palpate the abdomen and liver: Standing on the patient's right side, use the fingertips to palpate the abdomen in circular motions. To palpate the liver, place the right hand along the ribcage with the fingers pointing toward the ribcage. Instruct the patient to breathe in and exhale; as the patient exhales, press downward and toward the ribcage with a gentle pressure. Instruct the patient to take a deep breath; feel the liver border move against your hand. o Normal: Non-tender; no masses; no abdominal guarding; if palpable, the liver borders are smooth and firm

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