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NURSING ASSESSMENT AND COMMON FINDINGS (Abdomen (Patient should be placed…
NURSING ASSESSMENT AND COMMON FINDINGS
Health histoy
An assessment of patient past history including past and current use of medication,surgery or other treatments.
Medical
Data related to any hospitalisation and gastriointestinal surgery and blood tranfusions
Nutrition
Nutritional status in relation to food intake,elimination and nausea and vomiting by finding out if there's weight gain or loss.
eating pattern/appetite
Asking if the patient is eating well,food preferences,allergies nausea and voming.
Stool
Charecteristics of stool in relation to colour,shape, composition and nature.
Pain
Charecteristics of pain experienced
general iformation
Information relating to activity,rest and stressors.
Medications
Information on the use of non-steroidal anti-inflamattory drugs or antacids including frequency and duration of stage.
Elimination patterns
Bowel habits: regularity of defecation, diarrhea or constipation,relationship of defecation to food, pain experienced.
diarrhea
Diarrhoea occurannce in relation to food and pain.
Physical appearance
Inspection for height,weight,gait and general appearance.
The mouth and oropharynx
Inspection and examination of various stuctures forming the mouth for symmetry,colour and size.
Inspection of bucal mucosa for areas of pigmentation or lesions
Abdomen
Patient should be placed in supine position with knees slightly flexed and head slightly raised with a pillow.
Empty bladder
Patient must relax and breathe slowly.
Inspection
Abdomen should be inspected for symmetry and contours
Assess whether is flat,rounded,convex,concave or distended
Signs of obvious masses such as skin changes
Auscultation
Use diaphragm of the stethoscope to listen to bowel sounds
Warm the stethoscope to promote relaxation of the abdominal muscles
It should be done on four quadrants to elicit bowel and vascular sounds
Percussion
It establishes the presence of fluids,air and masses
All four quadrants must be percussed to distribute the dustribution of dulliness or tympany
Palpation
It may be light,moderate and deep.
Light palpation promote relaxation for deeper palpation
Light palpation is used to detect tenderness,hypersensitivity of the skin and swelling