Are you looking for an Abdominal assessment case study Example? You’re at the right place! An abdominal assessment plays a key role in the practice of nursing, involving the abdominal cavity’s thorough evaluation and its inside organs. This extensive process assists in tracking the course of the condition existing, identifying possible health complications, and tailoring relevant care.

This article on Abdominal assessment case study Example is an in-depth summary of the abdominal assessment techniques, including palpation, inspection, percussion, and auscultation. It also emphasizes the abnormal and standard findings to clearly understand, and precautions to guarantee effective and safe assessments. Don’t let your  nursing homework devastate you while you can hire our nursing assignment help.

What are the normal findings in the abdomen assessment?

The Abdominal assessment’s normal findings for your assignment writing include;

• Inspection Abdomen symmetric, soft, without distention; invisible scars or lesions
• Auscultation Sounds of bowel active and present in all four quadrants; no bruit
• Percussion Overall tympany with all quadrants scattered dullness; dullness noted in quadrant upper right above the body’s liver
• Palpation Soft abdomen with no rigidity, masses, pain, or swelling

How do you document an abdominal assessment?

Documenting the Abdominal Exam Skinny

If you are a new nurse practitioner, possibilities are you might render documentation challenging, especially when you do not have an EMR system prompting your physical examination findings input. Documentation is crucial to your patients’ care continuity, and to safeguarding yourself should patient encounter questions arise. Given the significance of this fundamental skill, you must spend ample time covering physical examination documentation, in no specific order (system-by-system).

The process of documenting an abdominal assessment includes;

What You Are Examining:

The abdominal examination consists of many elements, inspection, bowel sounds auscultation, percussion, and finally palpation being the most fundamental. The exam should be conducted in this particular order since auscultation after palpation can cause an inaccurate bowel sound representation. The patients must be lying flat on their back for the examination with their abdomen revealed – examining over clothes is not important!

Why are those components important?

• Inspection –The normal external abdomen evaluation. Bruising, for instance, might show trauma. Distention can be an ascites sign.
• Auscultation –Bowel sounds assessment, may give you the patients’ pathology clue. Bowel sounds absence, for instance, might indicate blockages.
• Percussion –The liver evaluation. This one involves a lot of practice.
• Palpation – Is your patient tender? In case so, in which of the quadrants? This provides you with info that’ll assist lead to the diagnosis. The tenderness of the upper right abdomen, for instance, may mean pathology of the gallbladder. The tenderness of the lower right abdomen might indicate appendicitis. Important Tip: Analyze tender areas lastly. Observe the facial expression of the patient as you conduct your examination for discomfort signs.

Buzzwords be aware of:

There are several physical examination tricks you might do to assist you make a  nursing diagnosis. These are several nurse practitioner’s basic tests to be cognizant of:

• Murphy’s Sign – Signifies the inflammation of the liver or gallbladder
• Rebound Tenderness – Signifies the inflammation of the peritoneal
• McBurney’s Point – It’s tenderness may signify appendicitis

Documentation of Sample Normal Examination:

A normal, basic, abdominal exam documentation must look something besides these lines:

The abdomen is symmetric and soft, and no tenderness with no distention. Absence of visible scars or lesions. Midline aorta with no visible pulsation or bruits. Midline umbilicus with no herniation. Normoactive and present bowel sounds in all 4 quadrants. Absence of splenomegaly or hepatomegaly masses noted.

Documentation of Abnormal Sample:

Note that an abdomen is split into 4 quadrants, the upper right quadrant, the lower left quadrant lower right quadrant, and the upper left quadrant. The central abdomen (epigastric area) might also be utilized as the documentation reference point. The more certain you might be concerning the abnormality area, the better.

Although you will not make use of all these components in the abnormal abdominal examination documentation on a similar patient, these are examples of several findings of abnormal physical abdominal exams you might need to take note of.

Abdominal exam abnormals may comprise:

• Guarding (location)
• Rigidity
• Tenderness (location)
• Rebound (location)
• Tenderness of McBurney’s point
• Positive Murphy’s Sign
• External findings (scarring, lesions)
• Trauma Signs (ecchymosis)
• Splenomegaly or hepatomegaly
• Masses (palpable or visible, texture, size, location, shape)
• Distention
• Abnormal sounds of bowel (hypoactive, absent, hyperactive)
• Visible pulsation or aortic bruit

What are the 5 steps of abdominal assessment?

The approved abdomen assessment order to apply in your Abdominal assessment case study Example paper includes inspecting, auscultating, percussing, and palpating the abdomen.

The order is distinct since bowel sounds auscultation might be altered in case percussion or palpation was conducted first, possibly resulting in erroneous findings. Auscultation before touch ensures the abdomen’s natural state of hearing.

1.      Inspection

An abdomen is examined by positioning the patient supine on the bed or examining the table. The knees and head must be assisted with folded sheets or small pillows for the musculature of abdominal wall relaxation and comfort. The arms of the patient must not be folded at the back of the head but must be sideways, as this strains the wall of the abdomen. Make sure the patients are covered appropriately to ensure confidentiality, while still revealing the abdomen of the patient as required for a careful evaluation. Assess the abdomen visually for overall masses, shape, all abnormal movements, and skin abnormalities

• Observe the whole abdominal wall’s general symmetry and contour. The abdomen contour is often defined as rounded, flat, sunken (scaphoid), bulging, or convex (protuberant).
• Distention assessment. Generalized abdominal distention can result from liquid or gas bowel distention, obesity, or buildup of fluid.
• Assess for bulges or masses, which might show structural deformities such as hernias or associated with abdominal organ disorders.
• Assess the skin of the patient for color uniformity, striae, integrity, or scarring. Striae are silvery or white prolonged marks that happen at the stretch of the skin, especially during excessive gain of weight or pregnancy.
• Note the umbilicus shape; it must be midline and inverted.
• Carefully note all scars, and tally the scars with your patient’s previous injury or surgery recollection.
• Document all abnormal pulsations or movements. Visible peristalsis of the intestines can result from obstruction of the intestines. Pulsations might be visible in especially thin patients’ epigastric areas, but otherwise must not be noted.

2.      Auscultation

The abdomen listening, or Auscultation comes after inspection for precise bowel sounds assessment. Make use of warmed stethoscopes to evaluate the characteristics and frequency of the bowel sounds of the patient (peristaltic murmurs).

Begin your evaluation by placing your stethoscope’s diaphragm gently on the patient’s skin area in the (RLQ), right lower quadrant, since sounds of the bowel are heard in the area consistently. Sounds of the bowel are generally gurgling, high-pitched, sounds irregularly heard. Move the stethoscope clockwise to the following quadrant around the wall of the abdomen.

It isn’t authorized to count sounds of the abdomen because the normal sounds of bowel activity might cycle with periods of peak-to-peak for as much as 50-60 minutes. The stomach produces most peristaltic murmurs, with the large intestines and the small intestines producing the remainder. Because the peristaltic murmur conduction is noted throughout all abdomen parts, the peristaltic murmur source isn’t always on-site where it’s heard. In case the peristaltic sound conduction is good, single location auscultation is considered appropriate.

Hyperactive sounds of the bowel might indicate gastroenteritis or bowel obstruction. Sometimes you might be capable of hearing the bowel sounds of a patient with no stethoscope, often defined as borborygmus or “stomach growling”. This is hyperactive sounds common example.

Hypoactive sounds of bowel might be existent with constipation, following paralytic ileus, abdominal surgery, or peritonitis. During the abdominal auscultation, you shouldn’t hear abdominal vascular sounds. In case heard, report the finding to a medical provider.

3.      Palpation

The abdomen touching or palpation entails the use of the fingers and palm (not your fingertips) to discover tenderness, palpable organs, or abnormal masses. During a patient’s abdominal palpation reporting pain in the abdomen, the nurse must palpate the area lastly. Bedside nurses primarily use light palpation to evaluate for tenderness, musculature, and abnormal masses. Advanced practice nurses use deep palpation techniques to evaluate for hypertrophied organs. Palpate the patient’s abdomen lightly by squeezing the skin about 1cm starting in the right lower quadrant. Continue moving around the patient’s abdomen clockwise.

Palpate the patients’ bladders for distention. Monitor your patient’s reaction to palpation, like rebound tenderness, pain, rigidity, or guarding. Guarding means abdominal musculature voluntary contraction, usually resulting from cold hands touch, fear, or anxiety. Rigidity means abdominal musculature involuntary contraction acting towards peritoneal inflammation, and it’s a reflex a patient can’t control. Another peritonitis or peritoneal inflammation sign is Rebound tenderness. To evoke rebound tenderness, the clinician controls pressure over a tenderness area and then removes the hand suddenly. If your patients wince with pain after the hand withdrawal, the test turns out to be positive

Note: In case your patients are under urinary retention care plan – have Foley catheters in place, your “Facilitation of Urine Elimination” chapter must include extra assessments.

4.      Percussion

You might observe advanced practice clinicians and other providers of health care performing abdominal percussion to obtain extra information. Percussing may be utilized to evaluate the spleen and liver or to determine the presence of (CVA) costovertebral angle tenderness, which is associated with kidney inflammation.

• Encourage your patient to drain their bladder before palpation.
• During the abdominal palpation, ask the patients to bend the knees while lying face upward to enhance abdominal muscle relaxation.

Conclusion

The abdominal examination can be defined as the abdominal evaluation by a provider of health care or a doctor. Mainly it’s significant because it generates patients’ internal organs vital information. The evaluation also avoids further complications through the detection of the health problems of a patient earlier.  Successful abdomen evaluation includes 4-step procedures, that must be followed in the order of inspecting, auscultating, percussing, and palpating the abdomen as summarized in this article on Abdominal assessment case study Example.

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