How do you document an abdominal exam?
Documentation of a basic, normal abdominal exam should look something along the lines of the following: Abdomen is soft, symmetric, and non-tender without distention. There are no visible lesions or scars. The aorta is midline without bruit or visible pulsation.
How would you describe an abdominal inspection?
The abdomen is inspected by positioning the patient supine on an examining table or bed. The head and knees should be supported with small pillows or folded sheets for comfort and to relax the abdominal wall musculature. The entire abdominal wall must be examined and drapes should be positioned accordingly.
What is normal shape of abdomen?
The normal contour of the abdomen is typically flat or rounded. A concave contour (inward curve of the abdomen that looks sunken in) is concerning because it can be associated with dehydration and malnutrition, and sometimes with anorexia nervosa and cancer.
Should abdomen be dull or tympanic?
The anterior gas-filled abdomen normally has a tympanitic sound to percussion, which is replaced by dullness where solid viscera, fluid, or stool predominate. The flanks are duller as posterior solid structures predominate, and the right upper quadrant is somewhat duller over the liver.
How do you describe abdominal mass?
An abdominal mass is an abnormal growth in the abdomen. An abdominal mass causes visible swelling and may change the shape of the abdomen. A person with an abdominal mass may notice weight gain and symptoms such as abdominal discomfort, pain, and bloating. Masses in the abdomen are often described by their location.
How do you describe normal bowel sounds?
Normal: Bowel sound consist of clicks and gurgles and 5-30 per minute. An occasional borborygmus (loud prolonged gurgle) may be heard.
Is a soft abdomen normal?
Normal: Abdomen is soft, rectus muscle is relaxed and no discomfort is elicited during palpation.
How would you describe a mass or a lump?
Lumps may be described as soft and fluctuant, firm or even ‘stony hard’. Fluctuation indicates a fluid swelling and this is elicited by compression of the swelling with displacement in two planes.
How do you document a lump?
How to describe a lump or mass
- Tenderness.
- Site.
- Size.
- Surface.
- Shape.
- Edge.
- Consistency.
- Fluid thrill.
How do nurses describe bowel sounds?
Abdominal Examination (Exam) Nursing Assessment – YouTube
What are the three types of bowel sounds?
Different Types of Bowel Sounds.
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When it comes to classifying bowel sounds, there are three distinct types:
- Normal bowel sounds.
- Hypoactive bowel sounds.
- Hyperactive bowel sounds.
Why do doctors tap their fingers on your abdomen?
An abdominal tap can help diagnose the cause of fluid buildup or the presence of an infection. It may also be done to remove a large amount of fluid to reduce belly pain.
What should abdomen feel like?
A generally resonant abdomen suggests much flatus whilst solid or liquid under the fingers will be dull. Sometimes it is helpful to use percussion to define the edge of the liver.
How do you describe and examine a lump?
Structure or consistency
The lump may be solid, fluid, or gaseous. Lumps may be described as soft and fluctuant, firm or even ‘stony hard’. Fluctuation indicates a fluid swelling and this is elicited by compression of the swelling with displacement in two planes.
How do you document normal bowel sounds?
Place the diaphragm of your stethoscope lightly over the right lower quadrant and listen for bowel sounds. If you don’t hear any, continue listening for 5 minutes within that quadrant. Then, listen to the right upper quadrant, the left upper quadrant, and the left lower quadrant.
What are the 4 parts in order for abdominal assessment?
The abdominal examination consists of four basic components: inspection, palpation, percussion, and auscultation. It is important to begin with the general examination of the abdomen with the patient in a completely supine position. The presence of any of the following signs may indicate specific disorders.
What are normal stomach sounds?
The noises your stomach makes, called borborygmi, are normal intestinal sounds that occur during the digestive process. “The smooth muscles that line the gut contract and squeeze food and gas through 30 feet of small intestine and large intestine.
What is a doctor looking for when he pushes on stomach?
Pressing on your stomach is a way to find out if the size of your internal organs is normal, to check if anything hurts, and to feel if anything unusual is going on. Looking, listening, and feeling are all part of a physical exam.
What organ is above the belly button?
Located directly behind the stomach, the pancreas lies deep in the center of the abdomen. Its position corresponds to an area 3-6 inches above the “belly button”, straight back on the back wall of the abdominal cavity. In fact, the bones of the spine are just a few inches behind the pancreas.
What does soft and tender abdomen mean?
Abdominal tenderness is generally a sign of inflammation or other acute processes in one or more organs. The organs are located around the tender area. Acute processes mean sudden pressure caused by something. For example, twisted or blocked organs can cause point tenderness.
What are the four types of abdominal pain?
There are four types of abdominal pain: upper, lower, right-sided and left-sided. Each type has specific symptoms and causes, and all are briefly discussed below (for detailed discussion click here).
Where is gas pain located?
Gas in the intestine causes pain for some people. When it collects on the left side of the colon, the pain can be confused with heart disease. When it collects on the right side of the colon, the pain may feel like the pain associated with gallstones or appendicitis.
How do you describe stomach pain?
Other terms used to describe abdominal pain are stomachache, tummy ache, gut ache and bellyache. Abdominal pain can be mild or severe. It may be continuous or come and go. Abdominal pain can be short-lived (acute) or occur over weeks, months or years (chronic).
What are the 3 types of abdominal pain?
There are four types of abdominal pain: upper, lower, right-sided and left-sided.
Why do I feel bloated and can’t pass gas?
Food intolerances. Gas or bloating may occur if your digestive system can’t break down and absorb certain foods, such as the sugar in dairy products (lactose) or proteins such as gluten in wheat and other grains. Constipation. Constipation may make it difficult to pass gas.