230 Week 2 Book and Lecture Notes
230 Week 2 Book and Lecture Notes NUR 230
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This 19 page Class Notes was uploaded by Issy Notetaker on Friday September 4, 2015. The Class Notes belongs to NUR 230 at Ball State University taught by Marjorie Pyron in Fall 2015. Since its upload, it has received 170 views. For similar materials see Health Appraisal Across the Lifespan in Nursing and Health Sciences at Ball State University.
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Jarvis Book Notes Chapter 3 Objectives Clinical Lecture 0 Interview O 0000 O 0 First contact point Collect data here Best chance to collect the subjective data Pt is in charge Chance to Gather COMPLETE and CORRECT information Establish trust Teach Build rapport Promote and prevent lnclude AIDET Confusion needs to be cleared up 0 Communication Process 0 O 0000 Based on behavior Conscious and unconscious Verbal and nonverbal Pt will pick up on if not sincere the behavior must have a meaning Will improve Verbal and nonverbal communication are equally important in sending the information Nonverbal communication includes body language Sender creates the message and gives it to receiver via verbal or written and receiver has to interpret the message and feedback ensures that the message was decoded correctly Be careful what and how thing are sent Eye contact is important aspect of communication Must be win speci c context to properly receive a message Receiver uses own interpretations based on experiences and culture Message is what is trying to be conveyed Feedback is what the receiver sends back to the sender Context is the setting in which the message is sent The sender sends a message within context to a receiver who gives feedback via spoken words or action lnner Factors affecting context and interpretation of information or message Views toward others liking respecting Ability to express empathy Feeling with and not like Listening ability active and demanding and demands focus to distinguish what is begin said from how it is being said Awareness of Self knowing own bias prejudices and stereotypes External Factors Setting where interview takes place 0 Dress Privacy should be given and advocate for privacy of pt from family or visitors Interruptions should be minimal Environment temperature lighting quiet nondistracting or cluttered respect personal space have equalstatus seating Electronic medical records Taking notes while giving interview breaking eye contact too often Pt in normal clothing if possible and interviewer should be dressed for setting and situation Taking notes is needed but it Breaks eye contact Shifts attention Causes pt to slow down speaking Distracts from observation Not good for sensitive topics Should not become a barrier to communication 0 Explain what it is for and allow pt to see 0 Be aware of bias and prejudice for culture gender preferences sexual preferences racereligion value systems SES 0 Communication Techniques 0 Introduce the Interview Keep short use last names unless asked to do otherwise Use AIDET State reason Let them discuss concern by asking open ended questions 0 Working PhaseData Collection 0 OpenEnded questions answered in narrative asked using general terms 0 CloseEndedDirect yesno response Speed up interview and offer speci c facts Ask only one at a time and choose a language that the pt is familiar with o Verbal Responses Therapeutic Communication Help enhance and egg on the story W Facilitation Silence Re ection Empathy and Clari cation involve your reactions too what pt has said W Confrontation Interpretation Explanation and Summary start to express own thoughts Active listening is being engaged in the conversation where listener gives feedback or summarizes what the other has said Equal status seating Dress P vacy Limit interruptions remove distraction limit note taking Promotion and Prevention 0 Nonverbal communication Movements gestures talking w hands can be distracting Expressions Cultural in uences Sitting on level ground Increases cooperative behavior and increases quality and perceptions about care Personal space zones Intimate Personal Social Public Power of touch Know if pt is okay with this 0 Defense Mech Regression Potty training goes well until traumatic event Denial Repression Projection Rationalization Undoing Abuse partners giving gifts to victums o Traps of Interviewing Nontherapeutic communication Stop Communication False Assurance Giving unwanted advice Using authority Avoidance Language Distancing Professional Jargon use Leading or Biased questions Talking more than needed Interruption Using quotWhyquot as a form of question 0 Nonverbal Communication skills Appearance Clothing hygiene general appearance Posture Open or Closed and des it change throughout the interview Gestures include dgeting Facial Expression Does it match the claims re ects emotions and conditions Eye Contact Know culture and aim to maintain Voice Tone intensity rate pitch and pauses Touch Don t use during interview unless know well 0 Closing Interview Should be Graceful Give a summary of what all was discussed Development 0 Interview ParentCaregiver Build trust w pt an caregiver O Greet by name but is lt6 years old pay more attention to caregiver Provide toys but don39t completely ignore Avoid becoming judgmental and accusing Stages of cognitive development Consider the stage of the child you are approaching Infant is nonverbal Preschooler uses simple words or is nonverbal Include older children in discussion USE PLAY AND TOYS Communication w Different Ages 0 Infant 012months coos cries and facial expressions 0 Toddler 1236months Development of communication skills has begun Telegraphic speech then begins with short 23 word sentences Preschool 36 years Egocentric 34 word sentences then 68 word sentences w well developed grammar SchoolAge 712 know other viewpoints know things affect others and are able to reason Adolescent Don39t treat like adult or child Need acceptance respect an validation should be conveyed should be honest be a nurse not a friend ask about life privacy is key use positive reinforcement Older adult address by surname longer story means more time w pt consider if the environment facilitates communication noisy fam use senses include the pt and avoid rushing 0 Interviews w Special Needs 0 O O HearingImpaired Ask preferred method of communication speak slowly use correct hand gestures sit facing don shout talk clearly Acutely Ill interview is combined w examination only needed information includes as much subjective as possible family is a great source Under the In uence behavior depends on drug used ask simple and direct nd out what was consumed last once sober perform full Personal Questions supply only appropriate information Sexually Aggressive people be clear that you are a professional and here for the job stress that you will not tolerate the behavior Crying Have tissues don39t leave the topic Anger Ask about and hear person out Threats of Violence Note red ag behaviors and act immediately to diffuse leave door open and don39t turn back Include other staff and think of security options Anxiety don39t look hurried ad take time Those needing interpreter Culture and Genetics 0 Gender Considerations Know culture allowances on what genders can be in the room together Know modesty rules 0 Sexual Orientation Use term like partner ask same questions as would be asked to a hetero couple know state laws use correct teaching aids DON39T MAKE ASSUMPTIONS be nonjudgmental o Interpreters Language barriers create negative outcomes Trained interpreters have a positive effect Try not to use family as interpreter but if have to make sure to document this Helps the bridge the gap Should have a trained interpreter on staff or use telephone interpretation line Speak to client not interpreter Use line by line for most of interview and summary interpretation little of the time to ensure accuracy 0 Health Lit Ability to understand the instruction understand and navigate the health care system and communicate concerns Tests include 0 Test of functional Health Lit Rapid Estimate of Adult Literacy in Medicine 0 Newest Vital Sign Just asking last grade level that was completed or if there are any learning disabilities Teaching Aids 0 Oral Give simple instructions and discussing information using simple terms 0 Written Materials Reading level of pt 12 point font appropriate graphics 0 Teach Back Ask is pt is understanding throughout the teaching have pt repeat back what was said Chapter 4 0 Health History 0 Purpose is to collect subjective data 0 Provides a picture of pt past and present health 0 Find out what person is doing correctly and wat person is doing incorrectly 0 Assess lifestyle 0 Important to guide physical assessment 0 Physical psychological social and sexual Data collected Date and time o Biographic Name address age and DOB along w place of birth different country or small townbig city gender relationship ethnic origin language that is primary or spoken at home and occupation 0 Source of information Was it from pt or family Is the informant reliable and was the informant willing to give information Is the person well or ill 0 Reason for seeking care Brief and in pt own words Symptoms or signs and duration Symptom is what pt feels sign is measurable Don39t record selfdiagnosis but record symptoms 0 Present healthillness Collect all data on present condition Note Location Speci c localized or radiating shallow or deep Characteristics Quality Describe Severity Quantity Scale and record what pt says Timing Onset duration frequency Setting Where and What was the pt doing when it started AggravatingRelieving Factors Associated Factors Is it primary to another issue Perception Alerts of anxiety or potential PQRSTU ProvocativePalliative QuantityQuality RegionRadiation SeverityScale Timing Understand Pt Perception 0 Past health Childhood Illnesses Accidents or Injuries Serious or Chronic illnesses Hospitalizations Operations Obstetric History Immunizations Last Exam Date Allergies Current Medication Look at age Older don39t have same immunizations as younger do may see illness as different 0 Family history Use Pedigree or Genogram Include medical conditions ages twinning death substance use Ask speci cally about certain medical conditions Go back three generations Details are very important 0 Culture and Genetics 0 Review of systems Evaluates past and present health of each system Systems assessment and great time to begin teaching Recheck signi cant data from health history Look for health promotion practices Head to toe order ONLY SUBJECTIVE DATA 0 Functional Assessment SelfCare ability General physical health ADLs Habits alcoholdrug use violence occupation hazards Detail is important SelfEsteem Stress and coping Relationships Resources available Activity Sleep Nutrition 0 Perception of Heath 0 Developmental Competence 0 Children Include information speci c for age and developmental stage Moms health during preg labor delivery perinatal period and family unit Ask for caregivers intuitive sense of the problem Past health should include pregnancy How are the parents handling he child Developmental History includes growth milestones current development and skills Nutritional History Younger the child more detailed Family History Review of systems Functional Assessment Interpersonal Relationships 0 Activity and Rest Economic Status Home Environment Environmental Hazards CopingStress Management Habits Health Promotion 0 Adolescent HEEADSSS Home Environment Education and Employment Eating Activities Drugs Sexuality SuicideDepression Safety 0 Older Adult Generation Obstetrical History 0 More preg increase risk of cervical cancer 0 Less preg increases risk of breast cancer Last exam and medications Functional mental cultural nutritional skin disease and age Past health 5 years Chapter 11 Nutritional Status 0 Balance bw nutrient intake an requirements 0 Optimal Suf cient nutrients are consumed to support activities and metabolic needs 0 Over nutrition Consumption is over body needs and can cause obesity diabetes hypertension ect 13 children are overweight and 16 are obese 23 adults are overweight w13 obese Needed nutrients the body must have for daytoday needs and an increased metabolic demands on growth pregnancy and iHness Leads to a more active lifestyle less illness and a longer life 0 Identify those who are malnourished or at risk 0 Obtain baseline nutritional data 0 Affected by psychological psychosocial developmental cultural and economic factors 0 Plate should be 12 fruits and veges 12 whole grains and protein lean meats sh beans eggs nuts with little amounts of sodium sat and trans fats cholesterol 0 Vitamins water soluble C and B and fat soluble ADEK 0 Minerals MgClCaPKNa Developmental Competence 0 Infants and Children 04 months is fastest growth period double weight I this period and triple it by 1 Length increases Lose 10 in rst day but gain back quickly Double weight at 4 months and triple at 1 year Breast feeding 5 recommended Age 2 brain is 50 of adult size and 100 by 8 gt2 should not have low fat or skim milk or be on low fat diets o Adolescence Rapid growth Increased need for protein and calories Nutritional snacks are important to meet the needs that 3 meals a day can39t reach Girls will double body fat earlier than boys Inactivity increases increasing risk for obesity 0 Pregnancy and Lactation 0 Adult Increased nutritional demands Weight should increase a predetermined amount based on mother weight Nutritional demands stabilize Education to preserve health is required Increased risk for Metabolic syndrome 0 Increased BP increased fasting glucose increased triglycerides increase waist circumference low HDL 0 Aging Adult Decreased energy requirements Increased need for nutrient dense foods Lose mm mass Sarcopenia Increase body fat Sarcopenic Obesity is when there is also a decrease in mm mass Change in taste and smell Dif culty swallowing and chewing Ability Polypharmacy poverty alcoholism 0 Know caloric intake for each age groups 0 Culture and Genetics Food customs are usually kept the same even after moving Under nutrition is common when moving to a new country Consider Frequency Number Form Content Amount Regularity and O O O 0 Types Dietary Practices of Groups Food preferences go w religious practices Keep fasting in mind 0 Types of Nutritional Assessment 0 Nutritional Screening is the rst step and contains easily obtained data identi es if at risk for nutritional risk 0 Assess Weight weight history conditions diet information lab data Tools include Malnutrition screening tool and Mini Nutritional Assessment Malnutrition costs money in complications If at nutritional risk more in depth screening occurs Comprehensive Nutrition Assessment dietary history clinical information physical measurements lab tests Methods 24hr Recall easiest and most popular 0 Everything in past 24 hours 0 Complete interview or questionnaire 0 Food Frequency Questionnaire will counter the items left out in 24 hour recall 0 Food diary is most accurate 0 Everything for a week is written down 0 Can be selfaltered Direct Observations will detect problems w eating Identi es at risk pt Subjective Data collected 0 Eating Patterns Normal and changes Weight Normal Changes in appetite taste smell chewing swallowing Recent surgery trauma burn infection Chronic illness Nausea Vomiting Diarrhea Constipation Food Allergies Medications and Supplements Patient Centered Care Alcohol or Drug use Exercise 0 History 0 Additional Data for Infants and Children 0 Gestational Nutrition 0 Breastfed vs Bottle Fed o Willingness to eat what was prepared 0 Overweight or obesity factors 0 Additional For Adolescents 0 Present weight 0 Use of steroids or others to increase mm mass 0 Overweight and Obesity risk factors 0 Age of Menarche Additional for pregnant women 0 of Pregnancies 0 Food Preferences 0 Additional for Aging Adult 0 Differences in diet from when 405 and 505 0 Objective Data 0 General appearance provides clues 0 Lab testing is needed for accurate diagnosis Hemoglobin Males 1418 gdL Females 1216 gdL Hematocrit Males 3749 Female 3646 Blood Sugar lt100 mgdL Cholesterol 120200 mgdL o Derived Weight Measures Percent usual body weight currentusual100 lt95 indicates a form of malnutrition OOOOOOOOOO O O O Recent UsualcurrentUsusal100 Unintentional loss of gt5 is signi cant BMI and of ideal Recent change in weight Waist to Hip Waist circumferenceHip circumference gt1 in men or 8 in women indicates android obesity Waist circumference gt35 inches in women or 40 inches in men increases risks Skinfold Thickness Estimate of fat Stores 10 gt OR lt is over or under nutrition Arm Span Height Look at skin hair nail eyes lips gums tongue MS and neurological Developmental Competence 0 Infant Child Adolescent BMI and skinfold thickness to determine obes y Pregnant Women Weight measured monthly until 30 weeks and then bimonthly last month weekly Increase calories protein vitamins minerals mainly iron folate and zinc Gain weight at a certain rate Aging Adult Height will decrease and arm span is a better measurement TSF is dif cult to get so BMI and Waist to Hip are better indicators Serial Assessment 0 O Monitors nutritional status of those malnourished Malnutrition types include obesity marasmus kwashiorkor and a mix of the two last ones Approaches to each must be individualized Features of good plan Regular exercise Eating low cal diet and low fat Monitoring daily intake Teaching moment Enjoy food but eat less Monitor portions Smaller Read labels lncrease activity Avoid empty calories Purpose of nutritional assessment is to determine is person is optimal over or under nutrition Abnormal o Obesity excess caloric intake Weight 20 above ideal or BMI of 30399 o Marasmus protein and caloric malnutrition inadequate intake due to starvation Weight lt80 normal 0 Kwashiorkor protein malnutrition diets high in calories but low in protein Normal weight and appear nourished but lab ndings are low M and K mix Prolonged low intake of protein due to starvation lt80 weight low lab ndings Scorbutic Gums Vitamin C de ciency Rickets Vitamin D de ciency Bitot Spots Foamy plaques from Vitamin A de ciency Pellagra Skin condition of Niacin de ciency Follicular Hyperkeratosis Vitamin A or linoleic acid de ciency causing dry bumpy skin Magenta Tongue Ribo avin de ciency 0 Under nutrition where all reserves are depleted More vulnerable Infant and children pregnant immigrants lower income hospitalized aging 0 Over nutrition excess consumption calories fats sodium and increases risk for obesity heart disease and diabetes 00000 O 0 Chapter 21 0 Surface Landmarks o Abdomen Large oval cavity Diaphragm to pelvis Four layers of at mm joined by linea alba Internal Anatomy 0 Viscera is internal organ cavity 0 Visualize each organ 0 Solid viscera maintain shape liver pancreas spleen adrenal glands kidneys ovaries and uterus Liver is in RUQ and extends to MCL lower edge and kidney are normally palpable Ovaries can only be palpated bimanually during pelvic exam Spleen is soft mass on posterolateral wall just under diaphragm Pancreas is soft and lobulated behind stomach in ULQ Kidneys RETROPERITONEAL protected by ribs 0 Left lies at 11th and 12 ribs Costovertebral angle 0 Right is 12cm lower than left 0 Hollow viscera change shape depending on content Stomach gallbladder small intestine colon and bladder Usually not palpable but may feel bladder or colon if containing excrement Small intestine is in all four quadrants o Belly Button is the Center of the four quadrants Note for redness and drainage or piercings 0 KNOW THIS CHART Upper Right Quadrant Liver and Gallbladder Duodenum Head of Pancreas Right kidney w adrenal gland Hepatic exure Part of ascending and transverse Colon Upper Left Quadrant Stomach Spleen Left Lobe of Liver Body of Pancreas Left kidney and adrenal Splenic Flexure Transverse and descending colon parts Lower Right Quadrant Cecum Appendix Ascending Colon Right ovary tube ureter Right spermatic cord Lower Left Quadrant Descending colon Sigmoid Colon Left ovary tube ureter Left Spermatic cord Midline Aorta Uterus Bladder Know Epigastric Stomach Transverse Colon NG tube placement Umbilical Hernia TlO Aortic Aneurysm and Suprapubic right above pubic bone and on bladder and rectum Regions Each is 13 of abdomen Developmental Competence 0 Infants and Children Newborn umbilical cord shows Liver takes up more space Bladder is higher Abdominal wall is less mm 0 Pregnancy Morning Sickness and Acid Indigestion are common causing constipation causing hemorrhoids Uterus pushes intestines up and backward Bowel sounds are less 0 Aging Adult More fat accumulates in suprapubic area Salivation decreases Esophageal emptying is delayed Gastric acid secretion decreases Increase in gallstone possibility Liver shrinks Increased chance of constipation Culture and Genetics o Lactose intolerance increases abdominal pain bloating and atulence Different rates among racial groups however not as much as once thought 0 Obesity Higher rates in blacks Subjective Data 0 Appetite Note changes Dysphagia and Dysarthria Food intolerance Abdominal Pain Nausea and Vomiting Constipation and Diarrhea Bowel Habits Past Abdominal History Medications Nutritional Assessment Blood and vomit in stool o Flatus ad Borborygmus Additional For Infants and Children 0 Breastfeeding or Bottle feeding Which table foods have been introduced How often do they eat Is there abdominal pain If there is a weight problem how long ls constipation present 0 BMI Additional for Adolescents 0 Eat regular meals 0 Exercise pattern 0 How much has been lost and how 0 Amount ofjunk food 0 BMI Additional for Aging Adult 0 How are groceries obtained and made Eat alone or share What was eaten yesterday How often are bowel movements BMI 0 Dif culty swallowing Objective Data 0 Expose abdomen fully in supine position w knees on pillow 0 Ask about painful areas 0 Have relax abdomen mm w breathing soft voice conversation Inspect the Abdomen o Contour Determine rib pro le to pubic bone Have pt prop up on elbows and look at contour for bumps or masses Know if distended protuberant at or scaphoid 0 Symmetry 000000000 00000 0000 Should be bilaterally Ask to breath deep to check for nonsymmetry Ask to sit up wout using hands 0 Umbilicus 0 Skin Should not be red or crusted Note if m or out Smooth Stroke w back of hand and even in color Color should match raceethnicity Note temp moisture diaphoretic or sweaty and texture Tugor Pinch Test Look for lesions anything abnormal describe and if unusual measure Note stretch marks pink of white old Look for venous pattern 0 Pulsation or Movement Pulsation from aorta 0 Hair Distribution Male pubic is diamond and female is triangle Consistent and even for male or female of the age 0 Demeanor Relaxed w normal breathing Ask if in pain or for any tenderness BEFORE palpation Auscultate Bowel and Vascular Sounds 0 Use diaphragm and hold lightly against skin beginning in RLQ at ileocecal valve area 0 Bowel sounds are air passing through intestines o Bowel Sounds Character and Frequency High pitched gurgling cascading Judge is hyper or hypoactive hyper can be caused by u or hungen As soon as hearing in that quad move to the next one If no sounds listen for min to declare hypoactive Have another listen and call physician Report as normal active hyperactive or hypoactive 0 Vascular Sounds Percuss Genera Bruits Use rm pressure to check over the aorta renal arteries iliac and femoral arties Usually no sound but if one occurs it is medium to low pitch lTympany Liver Span Splenic Dullness 0 General Tympany Lightly in all 4 quadrants moving clockwise Tympany should predominate dullness is not normal Resonance Hyperresonance Flat Dullness 0 Live Span Mapping out organs Measure height of liver in RMCL Start at lung and move down inti dull sound 5th intercostal space then move down and percuss up until dull again R costal Margin should be 612cm distance 0 Splenic Dullness Dull note bw 9th and 11th intercostal space and normally lt7 cm wide 0 Costovertebral Angle Tenderness Kidney hand over 12th rib and thump w ulnar edge of other st Thud but no pain 0 Special Procedures Ascites Free uid is peritoneal cavity Distended abdomen bulging anks protruding umbilicus Differentiate from gaseous distention by 0 Fluid Wave Place one hand on left ank and tap other ank with other hand this will create uid ow in abdomen if ascites o Shifting Dullness Here tympanic note as percussing if uid it will turn dull Ask to turn on side and repeat dull sound will be heard higher up Palpate Surface and Deeper areas Have person relax and lay down w knees bent up DO NOT palpitate if organ transplant suspected aortic aneurysm painful rst Judge size location and consistency Look for mass or tenderness Light and Deep 0 0 000 0 Liver Begin w light using 4 ngers and depressing lightly Use rotary motion moving skin and ngers then pick up ngers and move Notice Voluntary Guarding happens to cold tense or ticklish areas involuntary is constant hardness Do in all 4 quad and over bladder Note tenderness or masses Deep uses same technique but depress greater than 1 cm 5 8cm 0 Nurses don39t normally do this Bimanual can be used for obese or a large abdomen Separate masses from organs Then move on to particular organs RUQ place L hand under back and use R nger parallel to midline Push deep down and under W each breath move had up 12 cm You can try hooking technique too o Spleen Normally not palpable unless enlarge 3x Place hand like for liver but on LUQ and have L at an angle Nothing rm should be felt o Kidneys o Aorta Make a duck bill w hands at R ank and press rmly Either feel nothing or a round smooth sliding mass L is not normally palpable bc it sits higher but place hands like for liver w R hand perpendicular and press deep and no change should be felt Palpate pulse L of midline Aneurysm causes ngers to be spread apart 0 Special Procedures Rebound Tenderness When pain hold hand at 90 degrees and press down in area away from pain 0 Normal or negative is no pain 0 Pain on release con rms lnspiratory Arrest Place ngers under liver border and if pt can t take a deep breath wout pain test is positive lliopsoas MM Test 0 When acute abdominal pain hold R leg up and push down on lowest part of thigh is RLQ is in pain test is positive Alvarado Score for appendicitis MANTRELS score 0 Migration Anorexia Nausea and vomiting Tenderness RLQ Rebound Tenderness Elevated Temp Leukocytosis o Shift to the left OOOOOO Developmental Competence 0 Infant 0 Child Inspection Abdomen will be protruding Umbilical hernia and Diastasis Recti are common but disappear by childhood Auscultation Only bowel sounds Percussion Spleen is not Palpation Offer paci er and hold leg in one hand and palpitate with other 0 Not rst bowel movement as sticky greenish black Bladder and Liver are different size and location 4 Potbelly when standing Aging Adult Increased subcutaneous fat Organs are easier to palpitate Decreased salivation Esophageal emptying is delayed Decreased gastric secretions Increased in constipation Increased risk of gall stones Liver decreases in size and drug metabolism is decreased Pregnant Morning Sickness decrease in gastric motility displacement of organ reabsorbed H20 constipation and hemorrhoids painless abby papues caused by vascular pressure Abnormal Findings 0 000000 Obesity uniform round umbiicus is sunken in percussion and palpitation is normal Air or Gas Single Round Curve Auscultation depends on gas Pal and Percussion are abnormal Ascites Bulging anks Aus is normal Percus is dull over uid Pal is taught skin Ovarian Cysts Curve on lower 12 of abdomen normal Aus Percus is dull Pal aortic pulse Pregnancy Single Curve engorged breasts Aus Fetal heart sounds Percus dull over uterus Pal fetus Feces Localized distension Aus normal Percus scatter dullness over mass Pal rope like Tumor localized distension Aus is normal Percus is dull over mass Pal de ne borders Intestinal Obstruction Vomiting absence of voidinggas distended ab hyperactive bowel sounds dehydration fever hypovolemic shock ect Umbilical Hernia Soft skin covered mass common in premature an usually resolve by 1 year of age Hernia Protrusion of organ Epigastric Hernia Abdominal protrusion Incisional Hernia bulge near operative scar Diastasis Recti Midline ridge Succession Splash Loud splash in Aus over UQs Hypoactive Bowel diminished bowel sounds Hyperactive Bowel Loud and gurgling Peritoneal Friction Rub Rough grating sound peritoneal in ammation Vascular Sounds Arterial bruit turbulent ow Aortic aneuy Renal artery stenosis partial occlusion of femoral arteries Venous Hum Rare and hear in umbilical region Enlarged Liver Enlarged smooth not tender Enlarged Nodular Liver O Enlarged Gallbladder tender Enlarged Spleen Toward midline and can extend to left pelvis and usually not tender Enlarged Kidneys Similar shape as enlarged spleen no notch tympanitic percussion Aortic Aneurysm Most below renal arteries will hear bruit femoral pulses are decreased Ostomies Intestine is turned inside out on surface of skin when intestine or bladder function is lost Needed in colorectal cancer diverticulitis ln amed bowel Cohn39s disease removal of bladder Appendicitis tenderness in RLQ and migrating pain w rebound tenderness Needs surgical removal ln amed Gallbladder is cholelithiasis Flu like no pain Murphey and Blumberg sign Jaundice Pruritus Pain is intermittent and radiate to R shoulder tender abdomen