Health Assessment exam 3
Abdomen
• Inspect: Color, contour, scars, tats, etc.
• Auscultate: RLQ and clockwise
o Hyperactive: less than 30 sec
o Normoactive: 5-30 secs
o Hypoactive: less than 5 secs
o Absent: must listen for at least 5 min to confirm absence
o Borborygmus audible, high-pitched gurgling caused by increased peristalsis
• Percuss: tympany and dullness
• Palpate: lightly in all 4 quadrants
• Subjective data
o Personal history
o Nutrition
o Bowel functions
o Meds
o Family history
• Objective data
o Assessment
o Complications with palpations
§ Organ enlargement
§ Ascites
§ Peritoneal irritation
§ Signs of inflammation or appendicitis
• Nursing diagnosis
o Decrease in fluid volume
o Acute pain
o Nutrition imbalance
o Increase/decrease in food/fluids
o Diarrhea/vomiting
• Yellow tone: jaundice or liver condition
• Glistening: fluid buildup in the abdomen
• Striae (pink/purple): stretching of skin
• Dilated veins: liver disease
• Older adults
o Reduced: saliva production and stomach acid production
o Slowed: gastric mobility; peristalsis
Cardiac/Peripheral vascular
• Arrhythmias: abnormal heart rhythms with premature delay or irregular beats.
• Atrial fibrillation: irregularly irregular heart rhythm
• Emergency symptoms: chest pain, SOB, abnormal BP/inadequate perfusion
• Complete arterial occlusion: limb-threatening situation
Abdomen
• Inspect: Color, contour, scars, tats, etc.
• Auscultate: RLQ and clockwise
o Hyperactive: less than 30 sec
o Normoactive: 5-30 secs
o Hypoactive: less than 5 secs
o Absent: must listen for at least 5 min to confirm absence
o Borborygmus audible, high-pitched gurgling caused by increased peristalsis
• Percuss: tympany and dullness
• Palpate: lightly in all 4 quadrants
• Subjective data
o Personal history
o Nutrition
o Bowel functions
o Meds
o Family history
• Objective data
o Assessment
o Complications with palpations
§ Organ enlargement
§ Ascites
§ Peritoneal irritation
§ Signs of inflammation or appendicitis
• Nursing diagnosis
o Decrease in fluid volume
o Acute pain
o Nutrition imbalance
o Increase/decrease in food/fluids
o Diarrhea/vomiting
• Yellow tone: jaundice or liver condition
• Glistening: fluid buildup in the abdomen
• Striae (pink/purple): stretching of skin
• Dilated veins: liver disease
• Older adults
o Reduced: saliva production and stomach acid production
o Slowed: gastric mobility; peristalsis
Cardiac/Peripheral vascular
• Arrhythmias: abnormal heart rhythms with premature delay or irregular beats.
• Atrial fibrillation: irregularly irregular heart rhythm
• Emergency symptoms: chest pain, SOB, abnormal BP/inadequate perfusion
• Complete arterial occlusion: limb-threatening situation
