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    Procedure 28-15 Assessing The Abdomen

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    Procedure 28-15 Assessing The Abdomen

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    kirsten galleta
    12 views3 pages
    about the assessment of the abdomen

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    Procedure 28-15 Assessing the Abdomen

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    about the assessment of the abdomen

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    Download as doc, pdf, or txt
    12 views3 pages

    Procedure 28-15 Assessing The Abdomen

    Uploaded by

    kirsten galleta
    about the assessment of the abdomen

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    EMILIO AGUINALDO COLLEGE

    School of Nursing and Midwifery

    PERFORMANCE EVALUATION TOOL


    PHYSICAL ASSESSMENT

    Procedure 28-15: Assessing the Abdomen

    NAME OF STUDENT:
    SECTION/GROUP: Date:

    LEGEND:
    4 Very Satisfactorily Performed
    (Student performs consistently in an effective and efficient manner)
    3 Satisfactorily Performed
    (Performance is usually effective and efficient but not always)
    2 Fairly performed
    (Progress in performance is too slow to judge satisfactorily; task performance is not properly for majority of the
    time)
    1 Poorly performed
    (No progress in performance has been demonstrated, and or performance is consistently inefficient)

    Procedure 28-15: Assessing the Abdomen


    Preparation 4 3 2 1 REMARKS
    1.Assemble equipment and supplies:
     Examining light
     Tape measure (metal or
    unstretchable cloth)
     Water-soluble skin-marking
    pencil
     Stethoscope
    Procedure
    1. Introduce yourself; explain to the
    client what you are going to do,
    why it is necessary, and how he can
    cooperate.
    2. Wash hands and observe other
    appropriate infection control
    procedures.
    3. Provide for client privacy.
    4. Determine client’s history of the
    following:
     Incidence of abdominal pain: its
    location, onset, sequence, and
    chronology; its quality
    (description); its frequency;
    associated symptoms
     Bowel habits
     Incidence of constipation or
    diarrhea
     Change in appetite
     Food intolerances
     Foods ingested in last 24 hours
     Specific signs and symptoms
     Previous problems and treatment
    5. Assist the client to a supine
    position, with the arms placed
    comfortably at the sides.
    Place small pillows beneath the knees
    and the head to reduce tension in the
    abdominal muscles. Expose only the
    client’s abdomen from chest line to
    the pubic area to avoid chilling and
    shivering, which can tense the
    abdominal muscles.
    Assessment
    Inspection of the Abdomen
    6. Inspect the abdomen for skin
    integrity.
    7. Inspect the abdomen for contour
    and symmetry.
    Observe the abdominal contour while
    standing at the client’s side when the
    client is supine.
    Ask the client to take a deep breath
    and to hold it.
    Assess the symmetry of contour
    while standing at the foot of the bed.
    If distention is present, measure the
    abdominal girth by placing a tape
    around the abdomen at the level of
    the umbilicus.
    8. Observe abdominal movements
    associated with respiration,
    peristalsis, or aortic pulsations.
    9. Observe the vascular pattern.
    Auscultation of the Abdomen
    10. Auscultate the abdomen for bowel
    sounds, vascular sounds, and
    peritoneal friction rubs.
    Percussion of the Abdomen
    11. Percuss several areas in each of the
    four quadrants to determine
    presence of tympany and dullness.
    Use a systematic pattern: Begin in the
    lower left quadrant, then proceed to
    the lower right quadrant, the upper
    right quadrant, and the upper left
    quadrant.
    Percussion of the Liver
    12. Percuss the liver to determine its
    size.
    Palpation of the Abdomen
    13. Perform light palpation first to
    detect areas of tenderness and/or
    muscle guarding.
    Systematically explore all four
    quadrants.
    14. Perform deep palpation over all
    four quadrants.
    Palpation of the Liver
    15. Palpate the liver to detect
    enlargement and tenderness.
    Palpation of the Bladder
    16. Palpate the area above the pubic
    symphysis if the client’s history
    indicates possible urinary
    retention.
    17. Document findings in the client
    record.
    TOTAL
    GRADING SYSTEM

    Performance Score _________ x 90% = ______

    Punctuality and Grooming _________ x 10% = ______

    Total = ______

    Evaluated by: Conformed by:

    ____________________________ ______________________________
    Signature over printed name Signature over printed name

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