How do you document abdominal assessment for nursing?

How do you document abdominal assessment for nursing?

How do you document abdominal assessment for nursing?

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.

What questions do you ask during an abdominal assessment?

Abdominal pain

  • Does the patient use a single finger or spread the fingers and move the palm over much of the abdomen?
  • What is the nature of the pain? Note body language.
  • Are there any aggravating or relieving factors?
  • How often is the pain felt and how long does it last?
  • Is there radiation elsewhere?

How do you describe bowel sounds?

The intestines are hollow, so bowel sounds echo through the abdomen much like the sounds heard from water pipes. Most bowel sounds are normal. They simply mean that the gastrointestinal tract is working. A health care provider can check abdominal sounds by listening to the abdomen with a stethoscope (auscultation).

How many bowel sounds in a minute?

Bowel sound consist of clicks and gurgles and 5-30 per minute. An occasional borborygmus (loud prolonged gurgle) may be heard.

What must be kept in mind before abdominal assessment?

A long list of differential entities can be the cause of abdominal pain; these are well described in standard text books and recent reviews. Consequently, a complete history should be obtained, and a set of probable diagnostic possibilities should be entertained prior to starting the examination.

What is the first step when performing an 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 questions should you ask a patient with abdominal pain?

Some other important questions to ask the patient include:

  • Have you ever had this pain before?
  • Are there associated symptoms, such as nausea and vomiting and/ or diarrhea?
  • Have you noticed any black stools or blood in your stool?
  • Have you noticed blood in your urine?
  • Do you feel as though you have had a fever?

What is the normal sound of abdomen?

Normal: Bowel sound consist of clicks and gurgles and 5-30 per minute. An occasional borborygmus (loud prolonged gurgle) may be heard.

Are normal bowel sounds high or low pitched?

25 When should a therapist auscultate for bowel sounds, and what are the normal findings? Normal sounds are a result of peristaltic activity and consist of clicks and gurgles. Some abnormal bowel sounds are: High-pitched tinkling—usually from tension of air/fluid in a loop of dilated bowel.