Sunday, August 28, 2022

The nurse is performing an abdominal assessment and inspects the skin of the abdomen.. Listens to bowel sounds in all for quadrants

The nurse is performing an abdominal assessment and inspects the skin of the abdomen.
The nurse performs which assessment technique next?

a- Palpates the abdomen for size
b- Palpates the liver at the right rib margin
c- Listens to bowel sounds in all for quadrants
d- Percusses the right lower abdominal quadrant

Answer C.
The appropriate sequence for abdominal examination is inspection, auscultation, percussion, and palpation.

Auscultation is performed after inspection to ensure that the motility of the bowel and bowel sounds are not altered by percussion or palpation.

Therefore, after inspecting the skin on the abdomen, the nurse should listen for bowel sounds.

Abdominal skin examination:
Examination of the abdominal skin is an auxiliary method allowing to examine the disease by examining the color of the subject's abdomen, the regularity of the surface of the skin and the presence or not of growth of foreign bodies on the skin. If the abdomen skin appears white, pink or purple, it means that the subject has abnormal symptoms. Abdominal skin tests include rashes, pigmentation, imperfections and scars. And describe where it is.

Basic information:
- Specialist category: skin examination category: other inspections

- applicable sex: if men and women apply fasting: not fasting

- Tips: Before inspection, it is prohibited to apply the darker pigment to the skin, avoid strong scratches in the skin. Normal value
Under normal conditions, the skin of the abdomen is smooth and has no rash, no stain and no scar. Under normal conditions, the color of the abdomen skin is slightly clearer than the exposed part.

Clinical meaning:
Abnormal results An abnormal examination of abdominal skin gives rise to different types of rashes, suggesting different diseases.

(1)- Congestive or hemorrhagic rash: often occurs in cases of rash of high fever or certain infectious diseases (such as measles, scarlatin, typhus) and allergies to drugs.

(2)- Purpura or hives: may cause abdominal pain.

(3)- Purpura or hives: can cause abdominal pain.

The pigment anomaly is:
(1)- Brown pigmentation: dispersed in dark brown pigmentation, often in the form of hemochromatosis. Skin wrinkles (like groin and belt) are pigmented in brown and can be observed in cases of adrenal insufficiency (Addison disease). When a woman is pregnant, there is a brown pigmentation on the midline between the umbilicus and the pubic bone, which often persists until after delivery.

(2)-Signs of Cullen and Gray-Turner: subcutaneous migratory bruising around the umbilicus, the skin is blue, called a sign of Coulomb, observed during an acute hemorrhagic pancreatitis or an extra break in pregnancy -Uteurine. This sign can sometimes appear in the left size, so that the skin of this part is blue, due to the infiltration of blood in the lateral wall of the abdominal wall from the retroperitoneal space. Her name is Turner's sign.

(3)- Irregular pigmentation in the abdomen and size: observed in several neurofibromes.

People to be examined: patients with rash, pigmentation, abdominal lines, scars, imperfections, umbilicus, hair and groin.

Tabou front inspection: Avoid applying darker pigments on the skin, avoid strong scratches in the skin.

- Conditions for examination: the abdomen is completely exposed and the light is suitable.

Inspection process:
- Inspection process: the patient completely exposes his abdomen to the doctor, who observes the surface of the patient's skin from top to bottom and from left to right to check the presence of a rash, pigmentation, stretch marks , white lines and roses. Or purple lines and note the results of rashes, pigments, abdominal lines, scars, expectations, navel, hairs, groin.

Not suitable for the crowd:
- Inappropriate people: normal people with smooth skin and slightly lightened pigmented areas.

Adverse effects and risks: