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Physical Assessment - Foundations Caring | NRAD 201, Study notes of Nursing

Material Type: Notes; Class: Foundations/Caring; Subject: Nursing Registered Assoc. Deg.; University: Cuesta College; Term: Fall 2008;

Typology: Study notes

Pre 2010

Uploaded on 08/18/2009

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NRAD 201B
Week 6/F08 1
Physical Assessment
Abdomen
Information gathered
From the patient: subjective
When was your last BM
What was it like: small/large, hard/soft
Have you been passing gas (charted as flatus)
Do you feel full or bloated
From the nurse’s observations: objective
Character of BMs
% of meals taken
emesis, especially after meals
Physical assessment
Inspection
Landmarks: Craven p.404
- right upper quadrant (RUQ)
- left upper quadrant (LUQ)
- right lower quadrant (RLQ)
- left lower quadrant (LLQ)
Epigastric region
Umbilical region
Hypogastric or suprapubic
region
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Physical Assessment

Abdomen

Information gathered

† From the patient: subjective

„ When was your last BM „ What was it like: small/large, hard/soft „ Have you been passing gas (charted as flatus) „ Do you feel full or bloated

† From the nurse’s observations: objective

„ Character of BMs „ % of meals taken „ emesis, especially after meals „ Physical assessment

Inspection

† Landmarks: Craven p.

  • right upper quadrant (RUQ)
  • left upper quadrant (LUQ)
  • right lower quadrant (RLQ)
  • left lower quadrant (LLQ)

† Epigastric region † Umbilical region

† Hypogastric or suprapubic region

Auscultation

† Performed before palpation.

† Utilizes diaphragm of stethoscope. Bowel

sounds are high pitched.

† Begin RLQ - bowel sounds are normally

present here. Proceed to auscultate all four quadrants if necessary.

Bowel Sounds

† Active (normal): irregular,

gurgling, tinkling. 5-

30x/min. It is not necessary

to count!!

† Hyperactive: Loud, high

pitched, rushing. Increased

frequency.

† Hypoactive: < 5x/min.

Short, quiet sounds.

† Absent

Palpation

Light palpation: all four quadrants

† Normal:

  • soft, smooth, non-tender, pain free.
  • guarding

† Abnormal

  • Rigid, tense, hard, firm
  • tenderness, pain
  • guarding

Documentation - examples

† States, “I passed gas when I got up this morning.” Bowel sounds hypoactive. Abdomen firm, without tenderness on palpation. Ate 50% clear liquid breakfast without nausea/vomiting. M. Bright SN

† States, “My stomach hurts all over. I haven’t had a BM in two days!” Bowel sounds active. Abdomen large, soft, non- tender on palpation. M. Bright SN