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Abdominal Assessment.docx

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NUR1 239
Sandie Larouche

Abdominal AssessmentSubjective Data AppetiteDysphagiaFood intoleranceAbdominal pain cramp burning stabbing aching dull NauseaVomitingBowel habitsPast abdominal historyMedicationsNutritional AssessmentASK PATIENT TO URINATE before assessment Inspection 1Skin smooth uniform color and pigmentation vasculature striae pink bluish then silvery white lines about 16 cm long layers of skin are broken after rapid or prolonged stretching scars2Contour flat scaphoid abdo sucked in rounded protuberant abovebelow umbilicus everted can indicate presence of mass or ascites3Symmetry view from clients side foot of the bed behind the head if able4Movement respiratory movement retractions aortic pulsations nonexaggerated pulsation may be present peristaltic movement may be visibleMarked visible peristalsis indicates intestinal obstruction5Masses or nodules6Umbilicus midline inverted no discoloration inflammation or hernia7Veins only in thin patients a prominent vein could indicate portal hypertension cirrhosis ascites or vena caval obstructionAuscultationNote Always auscultate bowel sounds before touching the abdomen to prevent alteration of bowel sounds 1Bowel SoundsTipsUse the diaphragmLight pressure on a tender abdomenBegin in the RLQ and proceed clockwise Listen 1 min per quadrant to confirm the absence of bowel sounds Bowel sounds normally occur every 515 seconds highpitched occur 530xminoAbnormal hypoactive due to decreased motilitypossible obstruction
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