NR304 Exam 2 Study - 2023): Chamberlain College of Nursing Chapter 2...

NR304 Exam 2 Study Guide / NR 304 Exam 2 Study Guide (Latest-

2023): Chamberlain College of Nursing

Chapter 21 Abdomen

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 andcholeycistytis 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 toknow… ▪ Rectus Diastasis-separation of the rectusmuscles 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 yourknowledge A client reports abd. pain. How should the nurse proceed with the assessment?

• Deep palpation
• Assessing the painful area first
• Assessing the painful area last with light palpation
• Checking for warmth at the painful area

When auscultating a clients abd. the nurse detects gurgles over the RLQ. What should the nurse suspect?

• Decreased bowel motility
• Nothing abnormal
• Increased bowel motility
• Cramping

How long should the nurse listen with the stethoscope before documenting “absent” bowel sounds or “silent” abdomen??

The nurse is examining a client with suspected peritoneal inflammation. How should the nurse elicit rebound tenderness?

• Using lt. palpation noting tenderness over area
• Using deep palpation over the affected area
• Pressing the area firmly w/ one hand & releasing pressure while maintaining fingertip

contact

• Pressing the area firmly w/ one hand, releasing pressure quickly & noting tenderness

on release

The nurse should anticipate auscultating hypoactive bowel sounds (BS) when assessing which client?

• A client with c/o hunger
• A client w/ diarrhea
• A client w/ borborygmus
• A client recovering from abdominal surgery

The nurse assesses a client’s abdomen and inspects aconcave contour. The nurse shoulddocument

this finding as:

• Distended
• Rounded
• Scaphoid (Runners)
• Protuberant

Urinary System Structure and Function • Kidneys • Ureters • Bladder • Urethra • Renal Vasculature ARF/AKI (acute renal failure/acute kidney injury) 30mLs/hour measure with indwellingcatheter

Prerenal condition: Shock

• Prerenal- Sudden and severe drop in BP or interruption of blood flow to the kidneys

from severe injury or illness

• Intrarenal- Direct damage to the kidneys by inflammation, toxins, drugs, infection or

reduced blood supply

• Postrenal- Sudden obstruction of urineflow duetoenlarged prostate, kidney stones,

bladder tumor, or injury

Lifespan Considerations Infants & Children • Nocturnal enuresis-bed wetting at night • Hydration- Pregnant Female • Frequency & incomplete emptying of bladder Older Adult • Glomerular degeneration & loss of filtration • Voiding difficulty & pattern changes

Subjective Data -How frequently do you urinate? - When do you urinate the most?-Do you feel completely empty or does it feel like there is still urine there?-What color is it?