Chapter 13 Module I Abdominal and Gastrointestinal System Amanda Sourvelis, MSN, RN

Examination Observe general behavior and position Inspect abdomen for: Skin color, characteristics, contour Should be smooth Striae, scars, faint vascular network Contour usually sunken Abdominal Examination Have the patient to empty their bladder Position them supine Observe general behavior and position Does your patient exhibit any unusual findings such as restlessness, knees drawn up, are they lying very still? Are they rocking back and forth? Inspect abdomen from side of the bed using a light source Skin color, surface characteristics, contour, surface movements Surface characteristics should be Smooth, With centrally located umbilicus Skin color may be ligher because of lack of exposure Striae, scars, faint vascular network Contour usually sunken; Slight protrusion if overweight or obese

Examination Auscultate for bowel sounds Auscultate for vascular sounds Diaphragm of stethoscope Systematic progression Auscultate for vascular sounds Use bell over Aorta, renal, iliac, femoral arteries Epigastric area/around umbilicus for venous hum Examination Unlike other assessments, the abdominal assessment has a different order Auscultation follows inspection Why? So we don’t disrupt normal bowel sounds and cause increases peristalsis, which will give false bowel sounds Auscultate: BEFORE palpation and percussion Auscultate for bowel sounds Diaphragm of stethoscope lightly …. Why because pushing down will cause peristalsis Systematic progression begin in the RLQ where bowel sounds are almost always present Normal bowel sounds should be heard every 5-15 seconds Borborgmi;prolonged gurgles of hyperperistalis Bowel sounds may be documented as “ABSENT” after Listening in ALL four quadrants for Five minutes in each of the quadrants! Bowel sounds may be altered or absent with a paralytic ileus. Paralytic ileus: Obstruction of the intestine due to paralysis of the intestinal muscles. As you listen to the abdomen, Auscultate for vascular sounds especially with people with hypertension Use bell of stethoscope over Aorta, renal, iliac, femoral arteries for bruits which occurs with stenosis or occlusion of an artery Use bell over Epigastric area/around umbilicus for venous hum is rare and occurs with portal hypertension and cirrhotic liver

Examination Percussion If you suspect distention, fluid, or solid masses. Note the distribution of tympany and dullness Expect to hear tympany in most of the abdomen Expect dullness over the solid abdominal organs such as the liver and spleen. Tympany loud high pitch drumlike sound

Examination Palpate abdomen lightly Palpate abdomen deeply Tenderness, muscle tone No tenderness Palpate painful areas last Palpate abdomen deeply Tenderness, masses Observe for facial grimaces Ask to breathe slowly through mouth Examination Before palpation, ask the patient to bend their knees to relax their abdominal muscles And breath through their mouth with jaw open, this decreases voluntary guarding. Palpate all 4 quadrants of the abdomen lightly (1-2cm) with the pads of the fingers for Tenderness, muscle tone, surface characteristics No tenderness; Relaxed abdominal muscles Palpate painful areas last Watch the patients face for signs of discomfort Abdominal pain on light palpation suggests peritoneal irritation or inflammation. Involuntary rigidity (muscle spasm) typically persists despite relaxation maneuvers Palpate abdomen deeply 4-6cm use one hand on top of the other and slowly push down. if tenderness is known save this area for last on palpation. There should be no Tenderness, masses Observe for facial grimaces that indicate areas of tenderness Ask to breathe slowly through mouth to facilitate muscle relaxation Also check for rebound tenderness. Choose the sight away from the painful area hold your hand at a 90 degree perpendicular to the abdomen push down slowely and deeply the lift up quickly. A normal response would be negative or no increased pain when hand released. Always perform this test last.

Examination: Special Circumstances Percuss liver span Palpate around umbilicus Ring should be round, no bulges Palpate liver Examination: Special Circumstances! Indirect percussion of all quadrants: Assess density of abdominal contents Percuss liver span begin in the area of lung resonance and percuss down until the note changes to a dull quality. Mark the spot. Then find abdominal tympany and percuss upward and mark where the tone changes from tympany to dull. Palpate around umbilicus for bulges, nodules, umbilical ring Ring should be round, no bulges Umbilicus inverted or slightly everted Palpate liver for lower border and tenderness using the hooking technique Where you stand on the patients righ side place your hands side by side at the right costal margin and curve your fingers to hook them under the costal margin. Ask the patient to take a deep breath and you may feel the liver bump against your fingers during inspiration. The border should feel smooth with no tenderness.

Examination Palpate kidneys for Percuss kidneys for Presence, contour, tenderness Percuss kidneys for Costovertebral angle (CVA) tenderness Assess abdominal pain McBurney’s sign Iliopsoas muscle test Obturator muscle test Examination Page 280 Palpate kidneys for Presence Contour Tenderness Normally they are not palpable If your patient reports pain in the back (flank pain), Percuss kidneys for Costovertebral angle (CVA) tenderness Patient seated Direct or indirect Patient should feel thud, but no pain Tenderness or pain Pyelonephritis Kidney stone glomerulonephritis Assess abdominal pain R/T inflammation Test for rebound tenderness McBurney’s sign: Test for appendicitis Test for Rebound Tenderness Positive McBurney’s Point: Indicates Appendicitis Palpate halfway between umbilicus and anterior iliac crest Press firmly And release quickly Absence of pain is negative Page 284, Figure 13-23 Iliopsoas muscle test: Page 284, Figure 13-24 Patient supine Place your hand over lower right thigh Have pt raise right leg And flex hip Nurse to push down on the lower right thigh Resisting the patient as he/she is raising If patient c/o pain RLQ with pressure: Positive test Obturator muscle test: If ruptured appendix or abscess suspected Have patient supine Flex right hip to 90 degrees Nurse to Hold knee and ankle and Rotate leg medially and laterally Test is negative if no pain If pain in hypogastric region: Suspect ruptured appendix or pelvic abscess

Common Problems and Conditions: Alimentary Tract Gastroesophageal reflux disease Gastric secretions into esophagus Heartburn, regurgitation, dysphagia Hiatal hernia Protrusion of stomach Muscle weakness Peptic ulcer disease Duodenal ulcer Most common Gastric ulcers Caused by stress Problems and Conditions in the Alimentary Tract Gastroesophageal reflux disease backFlow of gastric secretions into esophagus Caused by incompetent lower esophageal sphincter, pyloric stenosis or motility disorder. Increased intraabdominal pressure Heartburn, regurgitation, dysphagia difficulty swallowing Aggravated by lying down Relieved by sitting up, antacids, eating Hiatal hernia A portion of the stomach herniates through the diaphragm and into the thorax. Herniation results from Muscle weakness R/T Pregnancy, obesity, ascites Heartburn, regurgitation, dysphagia, feeling of fullness Peptic ulcer disease A peptic ulcer is an ulceration in the mucosal wall of the stomach, pylorus, duodenum or esophagus in portions accessible to gastric secretions May have gastric, Duodenal ulcer or both May result from H. pylori infection Duodenal most common Most common; Break in mucosa; Forms scar Burning pain 2 to 4 hours after eating, midmorning, midafternoon, middle of night; relieved with antacids or eating Gastric ulcers Caused by stress; Steroids, aspirin, NSAIDs Burning pain in left epigastrium 1-2 hrs after eating

Crohn’s disease Chronic inflammatory bowel disease (IBD) Inflammation may occur from mouth to anus Commonly affects terminal ileum, colon Fistulas, fissures, abscesses Abdominal pain, diarrhea, nausea, fever, chills, weakness, anorexia, weight loss

Common Problems and Conditions: Alimentary Tract Ulcerative colitis May progress to colon cancer Abdominal pain, weight loss Profuse bloody diarrhea Diverticulitis Herniations through colon wall Cramping pain, distention Ulcerative colitis Starts in rectum, progresses through Large intestines May progress to colon cancer. Abdominal pain, fever, anemia, weight loss because of poor absorption of nutrients Profuse bloody diarrhea with mucus, pus Remissions and exacerbations. Diverticulitis Inflammation of diverticula, herniation's through muscular wall in colon Cramping pain in the lower left quadrant, N/V, usually constipation Abdomen distended, decreased bowel sounds Instruct patient to avoid gas forming foods or those containing seeds or nuts because these can become trapped in the pouches and cause inflammation.

Common Problems and Conditions: Hepatobiliary System Cirrhosis Chronic degenerative liver disease Viral hepatitis, alcohol abuse Ascites, jaundice Cholecystitis with cholelithiasis Inflammation of gallbladder (cholecystitis) With gallstones (cholelithiasis) Right upper quadrant colicky pain Radiates to right scapula Hepatobiliary System Cirrhosis Chronic degenerative liver disease Viral hepatitis, obstruction, alcohol abuse Ascites ( accumulation of fluid in the peritoneal cavity that results from venous congestion on the hepatic capillaries) Jaundice: liver is unable to metabolize bilirubin dark urine, clay-colored stools; End-stage cirrhosis is hepatic encephalopathy and coma Cholecystitis with cholelithiasis Inflammation of gallbladder (cholecystitis) With gallstones (cholelithiasis) Obstructed bile duct by edema, gallstones Right upper quadrant colicky pain Radiates to right scapula Mild jaundice

Common Problems and Conditions: Urinary System Urinary tract infections: Urinary bladder (cystitis) Urethra (urethritis) Renal pelvis (pyelonephritis) Gram-negative organisms Nephrolithiasis Formation of stones in kidney Stones, or calculi Fever, hematuria, flank pain that radiate to groin, genitals Urinary System Urinary tract infections: Urinary bladder (cystitis), urethra (urethritis), renal pelvis (pyelonephritis) Most from gram-negative organisms E coli, Klebsiella, Proteus, Pseudomonas Originate From patient’s GI tract; Urethra to bladder Symptoms include Urethritis: Frequency, urgency, dysuria (painful urination) Cystitis: Above, plus signs of bacteriuria fever more common in women because of their shorter urethra and close to the rectum Pyelonephritis: Flank pain, dysuria, nocturia, frequency Nephrolithiasis Formation of stones in kidney pelvis Urinary stasis and infection are important variables in the development of the stones. But also from diet high in calcium, vit d, milk, protein, dehydration, use of diuretics, catheters, immobilization, elevated uric acid levels such as gout. Assessment: renal and urethral colic which radiates through the genitals, sharp severe pain, dull aching pain over kidneys, nausea vomiting, low grade fever, high numbers of white, red blood cells and bacteria in the urinalysis. Hematuria. CVA tenderness. Problems resulting from stones are pain, obstruction, tissue trauma, secondary hemorrhage and infection. Located through radiography of the kidney, ureters and bladder, ct scanning and renal ultrasound.