Transcript The Abdomen
The Abdomen/Rectal The Abdomen Anatomy and Physiology The Abdomen Anatomy and Physiology The Abdomen Gastrointestinal Bleeding Upper Esophagus, stomach, duodenum Causes: Peptic ulcers- localized erosions of wall of digestive tract leading to damage of blood vessels and bleeding Gastritis- general inflammation of stomach wall which can result in bleeding Esophageal varices- swelling in veins in esophagus or stomach and usually associated with alcoholic liver cirrhosis Mallory-Weiss tears- a tear in the esophagus or stomach wall after vomiting, forceful coughing, laughing, lifting, childbirth, or recent binge drinking Also, ingestion of caustic poisons or stomach cancer Gastrointestinal Bleeding Lower Other segments of small intestine, large intestine, rectum, anus Causes: Diverticulosis- Small outpouchings from colon wall, usually in weakened area of bowel Angiodysplasia- Malformation in blood vessels of wall of GI tract. Often associated with elderly & chronic kidney failure Polyps- Noncancerous tumors of GI tract that occur mostly in those >40 y/o. Small number become cancerous Hemorrhoids- Swelling of veins around rectum, often from straining Anal fissures- tears in anal wall often from forced straining of hard stool Blood in stool can results from cancer, inflammatory bowel disease, infectious diarrhea Gastrointestinal Bleeding Acute Vomiting blood (hematemesis) (franks vs. coffee ground) Bloody bowel movement (hematochezia) Black tarry stools (melena) Fatigue, weakness, shortness of breath, pale appearance Associated with blood loss Long-term Fatigue Anemia Black stools Peritonitis An inflammation of the peritoneum the serous membrane that lines part of the abdominal cavity and viscera Causes: Peritoneal dialysis-An infection may occur during peritoneal dialysis due to unclean surroundings, poor hygiene or contaminated equipment. Ascites- Diseases that cause liver damage, such as cirrhosis, can result in a large amount of fluid buildup in your abdominal cavity, which is susceptible to bacterial infection. A ruptured appendix, stomach ulcer or perforated colon- Allow bacteria to get into the peritoneum through a hole in your gastrointestinal tract. Pancreatitis-Inflammation of your pancreas complicated by infection may lead to peritonitis if the bacteria spread outside the pancreas. Diverticulitis-Infection of small, bulging pouches in your digestive tract may cause peritonitis if one of the pouches ruptures, spilling intestinal waste into your abdomen. Trauma-Injury/trauma may cause peritonitis by allowing bacteria or chemicals from other parts of your body to enter the peritoneum. Peritonitis Common symptoms Acute abdominal pain Abdominal tenderness Abdominal guarding Rigidity Abdominal distention Fever & chills Nausea/vomiting Anorexia Decreased bowel sounds Inability to pass stool or gas Oliguria Fatigue Health History- GI Pain- Abdominal or rectal OLDCART Normal bowel habits/Stool character Presence of any of the following: Indigestion Belching (more than usual) Anorexia/Nausea/Vomiting Weight loss Difficulty swallowing (dysphagia) Flatulence (more than usual) Diarrhea Constipation Health History-GI Medications Aspirin, ibuprofen, steroids, antibiotics, laxatives, cathartics, codeine, iron preparations Abdominal surgery, trauma, or diagnostic tests of GI tract Personal or family history of: Cancer, alcoholism, polyps, chronic inflammatory bowel disease. Chance that pregnant? Risk factors for HBV exposure Health care occupation, hemodialysis, IV drug use, household/sexual contact with HBV + person, unprotected sexual practices Health History-GU Urinary/Renal Suprapubic pain Dysuria, urgency, or frequency Hesitancy, decreased stream in males Polyuria (>3L in 24 hours) or nocturia Urinary incontinence Hematuria (trace or gross) Kidney or flank pain History of kidney disease The Abdomen: Techniques of Examination Have Patient: Empty bladder Lye in Supine position Arms to the side or laying across chest Bend knees Point to any painful area Examiner Warm hands and stethoscope Watch patient’s face for signs of pain Distract patient if necessary Begin palpation with patient’s hand under yours if patient is ticklish, then slip your hand underneath directly Inspection Demeanor Knees drawn up, motionless, restlessness Contour of the abdomen Distention causes: Symmetry Obesity, air/gas, ascites, ovarian cyst, uterine fibroids, pregnancy, feces, tumor Bulges, masses, asymmetric shape Pulsations or movement Inspection Skin Scars, striae, dilated veins, rashes, lesions, or ostomy Umbilicus Assess for location, discoloration,inflammation, or hernia Everted- Ascites, pregnancy, mass, hernia Sunken- Obesity Bluish- Cullin’s sign indicator of intraabdominal bleeding Have pt raise head Abdominal wall mass, hernias, muscle separation Auscultation Listen to bowel sounds using diaphragm of stethoscope (high pitch). Begin in right lower quadrant and move clockwise to all 4 quadrants. Temporarily turn off GI tubes connected to suction Auscultation Bowel sounds Normal/Active - high pitched gurgling noise. Approx 5-35 sounds per minute, or at least 1 every 5-15 seconds. Hypoactive – Often soft and widespread. Less than 5 BS per minute. Absent – No bowel sounds heard. Must listen for 5 minutes before concluding that bowel sounds are absent Post operatively following general anesthesia Late stage bowel obstruction, paralytic ileus, peritonitis Hyperactive - Loud, gurgling, frequent sounds. Greater than 35 BS a minute. Inflammation of bowel, anxiety, diarrhea, bleeding, excessive ingestion of laxatives, rxn of intestines to certain foods Borborygmi – Loud stomach growling, rumbling sound produced by movement of gas in stomach and intestines. Heard with or without stethoscope Auscultation Arterial sounds for bruits Aorta Renal artery Iliac artery Femoral artery Use Bell Percussion Performed to detect fluid, gaseous distention, and masses, and to assess position and size of liver and spleen. Percuss in all 4 quads for tympany and dullness Large dull areas may indicate mass or enlarged organ Percussion The Kidney Assessing for costovertebral angle tenderness (CVA) Normal= non-tender Tenderness occurs in acute infection (pylonephritis) Palpation- Light Press fingertips gently into abdominal wall, approx ½ inch Use one hand approach Assess for abdominal tenderness, muscle guarding/rigidity, pulsations, large or superficial masses Palpation-Light Routinely check the bladder for distention if: Unable to void Incontinent Indwelling catheter is not draining well Bladder non-palpable without tenderness. Palpation - Deep Use two hand approach & press approx 1-3 inches. Assess masses, tenderness, and organ enlargement. Masses: Note location, size, shape, consistency, tenderness, pulsation. Never over surgical incision, extremely tender organs, or pulsatile mass Palpation - Deep Organs: liver Liver- Place left hand behind patient parallel to right 11th and 12th rib. Place right hand lateral to rectus muscle and well below lower border of liver. Press in and up. Ask patient to take deep breath. On inspiration normal liver palpable about 3cm below right costal margin in the midclavicular line Can use hooking technique Note tenderness (normally may be a little tender), should feel soft/firm, sharp, and regular with a smooth surface http://www.youtube.com/watch?v=Si0PHV991t0& feature=related The Abdomen: Abnormal liver Assessing for Cholecystitis Hold fingers under liver border Ask person to take deep breath Assess for sharp pain and abruptly stopping inspiration midway Negative Murphy’s sign (complete deep breath without pain) Assessing for Ascites A protuberant abdomen with bulging flanks suggests ascites Testing for shifting dullness Map borders between tympany and dullness. Ask patient to roll to side. Percuss and mark borders again. In ascites dullness shifts to more dependant side Assessing for Ascites Test for fluid wave Ask patient or assistant to press edges of both hands firmly down on midline of abdomen. While you tap one flank sharply with fingertips feel for fluid pulse on opposite flank with other hand Assessing for Appendicitis & Peritonitis Rebound Tenderness- Pain upon removal of pressure rather than application Rovsing’s sign- Rebound tenderness on the left lower quadrant Psoas sign- Pain with flexion of the right leg at the hip Obturator sign: Pain with rotation of the right leg internally at the hip Rectum/Anus Rectal/Anus exam includes inspection and palpation Position patient in left lateral or Sims’ position For prostate exam have bend over forward with hips flexed and upper body resting on table or bed. Drape the patient to avoid unnecessary exposure of genitalia Rectum/Anus- Inspection Perianal areas/Anus Masses/Rectal Prolapse Lesions Venereal warts, herpes, syphilitic chancre, or carcinoma Hemorrhoids Ulcers/Fissures/Fistulas Inflammation/Rashes Excoriation Use clock reference to describe lesion location Rectum/Anus- Palpation Lubricate gloved index finger prior to insertion As sphincter relaxes gently insert finger towards umbilicus Do not force finger Rotate hand clockwise Feel for tenderness, induration, irregularities/ nodules Colorectal Cancer Early stages often without symptoms so screening is key Change in frequency of bowel movements Constipation or diarrhea Pencil stools/feeling can’t empty bowel completely Hematochezia or melena Abdominal discomfort, bloating, frequent gas pains, or cramps Unintentional weight loss Anorexia Fatigue Anatomy of the Prostate Gland and Seminal Vesicles Prostate Gland Prostate gland Size Shape Surface Consistency Sensitivity Sample Charting Sample Charting (cont.)