NR 304 EXAM 2 STUDY GUIDE VERSION 2 / NR304 EXAM 2 STUDY GUIDE VERSION 2: LATEST,CHAMBERLAIN COLLEGE OF NURSING
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Course
NR 304 (NR304)
Institution
CHAMBERLAIN COLLEGE OF NURSING
NR 304 EXAM 2 STUDY GUIDE VERSION 2 / NR304 EXAM 2 STUDY GUIDE VERSION 2: LATEST,CHAMBERLAIN COLLEGE OF NURSINGNR 304 EXAM 2 STUDY GUIDE VERSION 2 / NR304 EXAM 2 STUDY GUIDE VERSION 2: LATEST,CHAMBERLAIN COLLEGE OF NURSINGNR 304 EXAM 2 STUDY GUIDE VERSION 2 / NR304 EXAM 2 STUDY GUIDE VERSION 2: LAT...
Structure and Function Abdominal Organs
Solid Viscera-doesn’t change shape, liver, spleen, ovary
Hollow Viscera-changes shape, stomach, intestine, bladder
Abdominal Muscles
Peritoneal Cavity-lines the abdomen
Visceral Peritoneum-lines organs, stressed and inflamed with appendicitis and
choleycistytis
Parietal Peritoneum-entire wall
Structure and Function Abdominal Vasculature
Abdominal Aorta-listen for bruit for aortic aneurysm. Caused by pressure
Renal Arteries-stenosis from plaque
Subjective Data
Appetite/wt. change
Dysphagia
Abdominal Pain
Nausea/Vomiting
Indigestion
Bowel Habits
Stool Assessment
Meds
Nutrition
Social Hx/Alcohol
Past Abdominal Hx
Stress
Family Hx
Lifespan Considerations
Infants & Children: Feeding & eating habits, GI function & nervous system maturation
r/t toilet training
Pregnant Female: Nausea, constipation, heartburn (pyrosis), Linea Nigra
Older Adult: Muscle tone, constipation, decreased peristaltic activity
Objective Data Abdomen
Inspection: Contour, symmetry, umbilicus, skin, pulsation
Auscultation: Bowel sounds (4 quadrants), vascular sounds (bruit)
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 an NG 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
When auscultating a clients abd. the nurse detects gurgles over the RLQ. What should the nurse
suspect?
1. Decreased bowel motility
2. Nothing abnormal
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