nr304 exam 2 study guide nr 304 exam 2 study guide latest 2022 chamberlain college of nursing |latest and updated guide|
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Chamberlain College Of Nursing
NR304
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, Percussion: Tone (4 quadrants), *Ascites(fluid in the abdomen, becomes protuberant) flip pt to
left-have tympana on right dull on left and vice versa assessment (p. 553). –want tympana due
to gas
Palpation: Light and deep palpation.
Special procedures:
Rebound tenderness (Blumberg at McBurney’s point) and Iliopsoas Sign-appendix, Murphy’s
Sign-gallbladder
Illeocecal valve RLQ –watery
Terms to know…
Rectus Diastasis-separation of the rectus muscles midline. keep abdominal contents in
place, pregnant women, body builders, abd. Surgery.
Cullen’s Sign-blue ring around umbilicus, internal bleeding
Borborygmi-really loud bowl sounds, hungry, negative sound when auscultating
Paralytic Ileus-and not walking. Bowel obstruction.
Melena-Blood in stool, oxidized blood. Black tarry thick stools
Shifting Dullness- ascites patients
Distended/Distention-gas, ascites
Guarding of the Abdomen-Involuntary and voluntary
What is involved in the ongoing assessment of a client with anNG tube to suction . . .?
WHY . . .? –Drainage, aspirate gastric contents every time before you insert anything,
turn off suction container when listening to bowel sounds
Nursing Diagnoses
Ineffective Nutrition: less than body requirements r/t nausea and vomiting
Constipation r/t decreased fluid & fiber intake, bed rest, medications
Risk for ineffective health maintenance r/t lack of knowledge of need for recommended
colon screenings
Pain, acute r/t inflammatory process
What Predicts What??
Hemoglobin 6.8
Burning Sensation in epigastric region
No Appetite
Nausea/Vomiting
Test your knowledge
A client reports abd. pain. How should the nurse proceed with the assessment?
1. Deep palpation
2. Assessing the painful area first
3. Assessing the painful area last with light palpation
4. Checking for warmth at the painful area
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