Mouth, Throat, Abdomen, Rectum

• Abdomen


  Bordered superiorly by the costal margins, bordered inferiorly by the symphysis pubis and inguinal canals, bordered laterally by the flanks

  
• Abdominal Wall Muscles


  • Three muscle layers from back, around flanks, to front: external and internal abdominus oblique, transverse abdominus
  • Protect internal organs, allow normal compression of internal organs during functional activities

  
• Solid viscera


  • Liver
  • Pancreas
  • Spleen
  • Kidneys
• Liver


  Helps with metabolism, produces bile, produces clotting factors, detoxifies drugs and alcohol, converts glucose to glycogen, stores vitamins A, B, E, K
• Pancreas


  Produces insulin, glucagon, helps produce enzymes to help with digestion, endocrine gland
• Spleen


  Produces RBCs, activates B and T cell lymphocytes, stores RBCs and platelets, helps with immunity
• Kidneys


  Maintain homeostasis, makes erythropoietin (helps stimulate RBCs)
• Hollow viscera


  • Stomach
  • Gallbladder
  • Small intestine
  • Colon
  • Urinary Bladder

  
• Current Symptoms


  • Abdominal Pain
  • Indigestion
  • Nausea and vomiting
  • Loss of appetite (anorexia)
  • Bowel movement (constipation and diarrhea)
  • UTI
  • Hepatitis
• Past History


  • Abdominal surgery, trauma, injury, medications
  • Abdominal pain and treatment
  • Lab work or gastrointestinal studies
• Family History


  • Stomach, colon, liver cancer
  • Abdominal pain, appendicitis, colitis, bleeding, hemorrhoids
  • Nutritional habits in family
• Lifestyle and Health Problems


  • Alcohol
  • Smoking
  • Diet
  • Antacid (with Magnesium, Aluminum)
  • Medications
  • Fluid intake
  • Exercise
  • Stress
  • Past actions with abdominal pain or problems
• Collecting Objective Data


  • Gather equipment (small pillow, ruler, stethoscope, marking pen)
  • Explain procedure to client
  • Empty bladder, remove clothes, lie supine, drape client, breathe through mouth
• Assessment of the Abdomen


  1. Inspection

  2. Auscultation

  3. Percussion

  4. Palpation
• Inspection


  • Observe skin coloration and vascularity
  • Inspect umbilicus, abdominal contour, symmetry, movements
• Auscultation


  • Bowel sounds (intensity, pitch, frequency)
  • Vascular sounds (venous hum, friction rub)
• Percussion


  • Percuss abdomen for tone, liver span, spleen
  • Blunt percussion on liver and kidneys
• Palpation


  • Light palpation for tenderness and guarding
  • Deep palpation for tenderness and masses
  • Palpate umbilicus, liver, spleen, kidneys, aorta, bladder, lymph nodes
• Special Abdominal Tests


  • Tests for ascites
  • Tests for appendicitis
  • Tests for cholecystitis
• Analysis of Data


  1. Formulate nursing diagnoses

  2. Formulate collaborative problems

  3. Make necessary referrals