chapter 21 test 2

8/13/2019 Chapter 21 Test 2

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Chapter 21 AbdomenFour layers of large, flat muscles form the ventral abdominal wall. These are joined at the midline by a tendinous

seam, the Linea Alba.

This is a test of version : 6h56 h56h h

Solid Viscera - are those that maintain a characteristic shape(liver, pancreas, spleen, adrenal glands, idneys, ovar

and uterus!.

Hollow Viscera" these depend on the contents (stomach, gal bladder, small intestine, colon, and bladder!.

The twelfth rib forms an angle with the vertebral column, the costovertebral angle. The left idney lies here at the

##thand #$thribs. %ecause of the placement of the liver, the right idney rest # to $ cm lower than the left idney ansometimes may be palpable.

The abdominal wall is divided into four &uadrants:

Epigastric the area between the coastal margins.

mbilical' the area around the umbilicus.

H!pogastric or S"prap"bic" the area above the pubic bone.

#he Aging Ad"lt

)*+T -- /0102T (/!

3iver

*all %ladder1uodenum

+ead of -ancreas

ight 4idney 0drenal

+epatic Fleure of 7olon-art of 0scending and Transverse 7olon

3FT -- /0102T (3/!8tomach

8pleen

3eft 3obe of 3iver

%ody of -ancreas3eft 4idney and 0drenal

8plenic Fleure of 7olon

-art of Transverse and 1escending 7olon

)*+T 39 /0102T (3/!

7ecum

0ppendi

ight 9vary and Tubeight reter

ight 8permatic 7ord

3FT 39 /0102T (33/!

-art of 1escending 7olon

8igmoid 7olon

3eft 9vary and Tube3eft reter

3eft 8permatic 7ord

;)13)20orta

retus (if enlarged!

%ladder (if distended!


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Anore(iais a loss of appetite from gastrointestinal disease, as a side effect of some medications with pregnancyor with psychological disorders.

)!sphasiaoccurs with disorders of the throat or esophagus.

*ood intolerance (e.g. lactase deficiency resulting in bloating or ecessive gas after taing mil products!.

+!rosis (heartburn!, a burning sensation in the esophagus and stomach, from reflu of gastric acid.

Abdominal painmay be visceral from an internal organ (dull, general, poorly locali@ed!Cparietal frominflammation of overlying peritoneum (sharp, precisely locali@ed, aggravated by movement!C or referredfrom adisorder in another site. 0cute pain re&uiring urgent diagnosis occurs with appendicitis, cholecystitis, bowel

obstruction, or a perforated organ.

,a"seavomitingis common with *.). disease, many medications, and with early pregnancy.

Hematemisis(coffee grind material, bleeding! occurs with stomach or duodenal ulcers and esophageal varices.

0ssess usualbowel habits. lac/stoolsmay be tarry due to occult blood (melena! from *.). bleeding or non"tarry from iron medications. $ra! stoolsoccur with hepatitis.

How do !o" ac0"ire !o"r groceries and prepare !o"r meals" assess ris for nutritional deficit: limited accethe grocery store, income, or cooing facilitiesC physical disability (impaired vision, decreased mobility, decrea

strength, and neurologic deficit!. Food pattern may differ during the month if monthly income (e.g. 8ocial ,

8ecurity chec! runs out.

S/in

9ne common pigment change is striae(leneae albicantes! " silver! white, linear, jagged mars about # to 6 cm

long. They occur when elastic fibers in the reticular layer of the sin are broen after rapid or prolongedstretching, as in pregnancy or a lot of weight gain. ecent striae are pin/ or bl"e then the! t"rn silver! whit

+"lsation or movement

;ared pulsation of aorta occurs with widened pulse pressure (e.g. hypertension, aortic insufficiency,thyrotoicosis! and with aortic aneurysm.

Abdominal Assessment - nspect3 A"sc"ltate3 +erc"ss3 +alpate.

s"al Assessment - nspect3 +alpate3 +erc"ss3 A"sc"ltate.

A"sc"ltate owel So"nds 4 Vasc"lar So"nds

1epart from the usual eamination se&uence and auscultate the abdomen net. This is done because percussion

and palpation can increase peristalsis, which would give a false interpretation of bowel sounds. se the diaphra

endpiece because bowel sounds are relatively high pitched. +old the stethoscope lightly against the sinC pushintoo hard may stimulate more bowel sounds. %egin in the 3/ at the ileocecal valve area because bowel sounds

are normally always present here.

owel So"nds

2ote the character and fre&uency of bowel sounds. %owel sounds originate from the movement of air and fluid

through the small intestine. 1epending on the time elapsed since eating, a wide range of normal sounds can occ%owel sounds are high pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5 to B> times

minute. 1o not bother to count them. 5"dge i6 the! are normal3 h!poactive3 or h!peractive.9ne type of hyperactive bowel sounds is fairly common. This is the hyper peristalsis when you feel your


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Vasc"lar So"nds

0s you listen to the abdomen, note the presence of any vascular sounds or bruits. sing firmer pressure, chec

over the aorta, renal arteries, iliac, and femoral arteries, especially in people with hypertension. sually, no such

sound is present. +owever, a small number of healthy persons (usually younger than > years! may have a norm

bruit originating from the celiac artery. This is systolic, medium to low in pitch, and heard between the iphoidprocess and umbilicus.

$eneral #!mpan!

First, percuss lightly in all four &uadrants to determine the prevailing amount of tympany and dullness. ;ove

clocwise. #!mpan! sho"ld predominatebecause air in the intestines rises to the surface when the person issupine - Dullness occurs over a distended bladder, adipose tissue, fluid, or a mess.

Hyperresonance is present with gaseous distention.

Liver Span

2ormal liver span in the adult ranges from 6 to #$ cm'an enlarged liver span indicates big liver (Hepatomega

Splenic )"llness

9ften the spleen is obscured by stomach contents, but you may locate it by percussing for a dull note from the

7thto 11thintercostal spacejust behind the left midaillary line. The area of splenic dullness normally is not

wider than A cm in the adult and should not encroach on the normal tympany over the gastric air bubble - a dul

note forward of the midaxillary line indicates enlargement of the spleen, as occurs with mononucleosis,trauma, and infection.

Costovertebral Angle #enderness

To assess the idney, place one hand over the #$thrib at the costovertebral angle on the bac. Thump that hand

with the ulnar edge of your other fist sharp pain occurs with inflammation of the idney or paranephric are

Special +roced"res

0t times, you may suspect that a person has ascites (free fluid in the peritoneal cavity! because of a distended

abdomen, bulging flans, and an umbilicus that is protruding and displaced downward !scites occurs withheart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.

Gou can di66erentiate ascitesfromgaseous distentionby performing two perc"ssion tests.

1. *l"id 8ave First, test for a fluid wave by standing on the personHs right side. -lace the ulnar edg of another eaminers hand or the patientHs own hand firmly on the abdomen in the

midline (this will stop transmission across the sin of the upcoming tap!. -lace your

left hand on the personHs right flan. ith your right hand, reach across the abdome

and give the left flan a firm strie '"f ascites is present, the blow will generate a

fluid wave through the abdomen and you will feel a distinct tap on your left-hand.

the abdomen is distended from gas or adipose tissue, you will feel no change.

2. Shi6ting )"llness )n a supine person, ascetic fluid settles by gravity into the flans, displacing th

air filled bowel upward. Gou will hear a tympanitic note as you percuss over thtop of the abdomen because gas filled intestines float over the fluid. Then percdown the side of the abdomen. )f fluid is present, the note will change from

tympany to dull as you reach its level. ;ar this spot. 2ow turn the person ont

the right side. The fluid will gravitate to the dependent (in this case, right! side

displacing the lighter bowel upward. %egin percussing the upper side of the ofabdomen and move downward. The sound changes from tympany to a dull sou

as you reach the fluid level, but this time the level of dullness is higher upward

towardwith the umbilicus. This shifting level of dullness indicates the presencof fluid "#hifting Dullness is positive with a large volume of ascitic fluid$ it w

not detect less than %&& m' of fluid.


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+alpate S"r6ace And )eep Areas

-erform palpation to judge the si@e, location, and consistency of certain organs and to screen for an abnormal mass

tenderness.

Light And )eep +alpation

%egin with light palpation. ith the first four fingers close together, depress the s/in abo"t 1 cm.Ioluntary guarding occurs when the person is cold, tense or ticlish. )t is bilateral, and you will feel the muscles re

slightly during ehalation. se the relaation measures to try to eliminate this type of guarding, or it will interferewith deep palpation. )f the rigidity persists, it is probably involuntary" involuntary rigidity is a constant, board lie

hardness of the muscles. "t is a protective mechanism accompanying acute inflammation of the peritoneum. "t mbe unilateral, and the same area usually becomes painful when the person increases intra-abdominal pressure by

attempting a sit up.

2ow perform deep palpation using the same techni&ue described above but this time down push down abo"t 9 to

cmand move clocwise to eplore the area.

,ormal *indings

;ild tenderness normall! is present when palpating the sigmoid colon . 0ny other tenderness should beinvestigated. )f you identify a mass, first distinguish it from a normally palpable structure or an enlarged organ. The

note the following:

#. 3ocation$. 8i@e

B. 8hape

. 7onsistency (8oft, Firm, +ard!5. 8ervice (8now, 2odular!

6. ;obility ()ncluding ;ovement ith espirations!

A. -ulsatility

E. Tenderness

Liver

0s the person to breathe slowly. ith every ehalation, move your palpating hand up # or $ cm. )t is normal to fe

the edge of the liver. %ump your fingertips as the diaphragm pushes it down during inhalation. )t feels lie a firm,regular ridge. 9ften, the liver is not palpable and you feel nothing firm.

Spleen

2ormally, spleen is not palpable and must be enlarged three times its normal si@e to be felt " the spleen enlarges wimononucleosis, trauma, leuemias, and lymphomas. "f you feel an enlarged spleen (spleenomegaly), refer the

person but do not continue to palpate it. !n enlarged spleen is friable and can the rupture easily with

overpalpation.


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Special +roced"res 6or Advanced +ractice

ebo"nd #enderness =l"mberg Sign>" assess rebound tenderness when the person reports abdominal pain or

when you elicit tenderness during palpation. 7hoose a site away from the painful area. +old your hand D>J, or

perpendicular, to the abdomen. -ush down slowly and deeply then lift up &uicly. 0 normal, or negative, response

no pain on release of pressure. -erform this test at the end of the eamination, because it can cause severe pain andmuscle rigidity " pain on release o6 press"re con6irms rebo"nd tenderness3 which is a reliable sign o6 peritoneain6lammation. +eritoneal in6lammation accompanies appendicitis

nspirator! Arrest =;"rph! Sign>" normally, palpating the liver causes no pain. )n a person with inflammation o

the gallbladder (cholecystitis!, pain occurs. +old your fingers under the liver border. 0s the person to tae a deepbreath. 0 normal response is to complete the deep breath without pain. (2ote: this sign is less accurate in patientsolder than 6> yearsC evidence shows that $5? of them do not have any abdominal tenderness.! " 8hen the test is

positive3 as the descending liver p"shes the in6lamed gallbladder onto the e(amining hand3 the person 6eels

sharp pain and abr"ptl! stops inspiration midwa!.

liopsoas ;"scle #est" perform the iliopsoas muscle test when the acute abdominal pain of appendicitis is suspect

ith the person supine, lift the right leg straight up, fleing at the hip, then push down over the lower part of the rig

thigh as the person tries to +old the leg up. hen the test is negative, the person feels no change " when the iliopsomuscle is inflamed (which occurs within an inflamed or perforated appendi!, pain is felt in the right lower &uadran

Common Sites %6 +re6erred Abdominal +ainEsophag"s' *astroesophageal reflu disease

(*1! is a comple of symptoms of esophag

including burning pain in midepigastrium or b

lower sternum that radiates upward, or to 6> minutes after eatingC aggravat

lying down or bending over.

$allbladder ' 7holecystitis is biliary colic, s

pain in right upper &uadrant that may radiate t

right or left scapula, and which builds over tim

lasting $ to hours, after ingestion of fatty fooalcohol, or caffeine. 0ssociated with nausea an

vomiting and with a positive ;urphy sign or asudden stop in inspiration with / palpation

)"oden"m ' 1uodenal ulcer typically has du

aching, gnawing pain, does not radiate, may be

relieved by food, and may awaen the person sleep.

Stomach ' *astric ulcer pain is dull, aching,

gnawing epigastric pain, usually brought on by

food, radiates to bac or substernal area. -ain

perforated ulcer is burning epigastric pain of sonset that refers to one or both shoulders.

Appendi( ' typically starts as dull, diffuse pperiumbilical region that later shifts to severe,

sharp, persistent pain and tenderness locali@ed

3/ (;c%urney point!. -ain is aggravated bymovement, coughing the, deep breathingC asso

with anoreia, then nausea and vomiting, feve

chapter 21 test 2

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