Abdominal Assessment
This assessment must be done IN ORDER to comply with the critical elements for this AOC,otherwise it is a fail.This is not a difficult one at all. I use :P X3IAFM, Pain In Abdomen From Motherhood.
P-pee. Ask the Pt if they need to use the bathroom before you start.It may be quite a distraction to have them exit the bed mid exam when you stimulate the bladder.
P- pain? Ask if the patient to point to , but not touch any areas that have pain or tenderness.
P-Position the pt spine with knees raised. If they have respiratory issues and a lowered head is contraindicated, verbalize CDM and reasons to CE. Provide privacy,expose only the area you need to assess.
I-Inspect-Look at the abdomen from xyphoid process to symphysis pubis, taking note of any contour, scars, dressings,bruising even condition of the umbilicus.Note the appearance of a stoma, if one is present.
A- Auscultate all four quads for bowels sounds, using the dual stethoscope.In order to declare absent bowels sounds , you must listen for a FULL minute. Hyperactive and hypoactive bowel sounds are abnormal findings and ought to be noted, although you will only be scored on being able to distinguish between presence and absence of bowel sounds.TURN SUCTION OFF. Suction will alter bowels sounds.TURN SUCTION ON!
F-Feel abdomen in each quadrant for tenderness or rigidity.Note the Pt reaction while you are doing this. is there any guarding? moaning?grimacing? LIGHTLY (about 1 inch depth) palpate,assessing any areas the pt stated were tender last. You may palpate around a dressing.The dressing does provide a barrier if it is dry, but to be safe I would wear gloves.
M- Measure girth of the abdomen if assign.there may be markers in place where the pt was perviously measured. Standard level is at umbilicus.
R- Record all assessment data collected regarding distention,presence or absence of bowel sounds in the four quads,tenderness or rigidity,abdominal girth (if assigned)
P-pee. Ask the Pt if they need to use the bathroom before you start.It may be quite a distraction to have them exit the bed mid exam when you stimulate the bladder.
P- pain? Ask if the patient to point to , but not touch any areas that have pain or tenderness.
P-Position the pt spine with knees raised. If they have respiratory issues and a lowered head is contraindicated, verbalize CDM and reasons to CE. Provide privacy,expose only the area you need to assess.
I-Inspect-Look at the abdomen from xyphoid process to symphysis pubis, taking note of any contour, scars, dressings,bruising even condition of the umbilicus.Note the appearance of a stoma, if one is present.
A- Auscultate all four quads for bowels sounds, using the dual stethoscope.In order to declare absent bowels sounds , you must listen for a FULL minute. Hyperactive and hypoactive bowel sounds are abnormal findings and ought to be noted, although you will only be scored on being able to distinguish between presence and absence of bowel sounds.TURN SUCTION OFF. Suction will alter bowels sounds.TURN SUCTION ON!
F-Feel abdomen in each quadrant for tenderness or rigidity.Note the Pt reaction while you are doing this. is there any guarding? moaning?grimacing? LIGHTLY (about 1 inch depth) palpate,assessing any areas the pt stated were tender last. You may palpate around a dressing.The dressing does provide a barrier if it is dry, but to be safe I would wear gloves.
M- Measure girth of the abdomen if assign.there may be markers in place where the pt was perviously measured. Standard level is at umbilicus.
R- Record all assessment data collected regarding distention,presence or absence of bowel sounds in the four quads,tenderness or rigidity,abdominal girth (if assigned)
posted by taming the beast at 10:10 AM
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