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The nurse suspects a hernia if a protrusion appears

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*The nurse suspects a hernia if a protrusion appears on the client’s abdomen when the nurse asks the client to cough or bear down.Involuntary reflex guarding is a sign of peritoneal irritation and the client should be assessed further for possible infection.*Deeply palpate all quadrants to delineate abdominal organs and detect subtle masses.Using the palmar surface of the fingers, compress to a maximum depth (5–6 cm).Normal : -Normal (mild) tenderness is possible over the xiphoid, aorta, cecum, sigmoid colon, and ovaries with deep palpation.Abnormal: -Severe tenderness or pain may be related to trauma, peritonitis, infection, tumors, or enlarged or diseased organs.Palpate for massesNote their location, size (cm), shape, consistency, demarcation, pulsatility, tenderness, and mobility. Do not confuse a masswith an organ or structure.Normal : - No palpable masses are present.Abnormal : - A mass detected in any quadrant may be due to a tumor, cyst, abscess, enlarged organ, aneurysm, or adhesions.Palpate the umbilicus and surrounding area for swellings, bulges, or masses.Normal : - Umbilicus and surrounding area are free of swellings, bulges, or masses.Abnormal: - A soft center of the umbilicus can be a potential for herniation. Palpation of a hard nodule in or around the umbilicusmay indicate metastatic nodes from an occult gastrointestinal cancer.Palpate the aortaUse your thumb and first finger or use two hands and palpate deeply in the epigastrium, slightly to the left of midline.Assess the pulsation of the abdominal aorta.Normal : - The aorta is approximately 2.5–3.0 cm wide with a moderately strong and regular pulse. Possibly mild tenderness may beelicited.
Abnormal: - A wide, bounding pulse may be felt with an abdominal aortic aneurysm. A prominent, laterally pulsating mass above theumbilicus with an accompanying audible bruit strongly suggests an aortic aneurysm*Older Adult Considerations : If the client is older than age 50 or has hypertension, assess the width of the aorta**it may be a dissecting aneurysm that can rupture from the pressure of palpation. Also avoid deep palpation over tender organs as inthe case of polycystic kidneys, Wilms tumor, transplantation, or suspected splenic trauma*Palpate the liverNote consistency and tendernessTo palpate bimanually, stand at the client’s right side and place your left hand under the client’s back at the level of theeleventh to twelfth ribs. Lay your right hand parallel to the right costal margin (your fingertips should point toward theclient’s head). Ask the client to inhale, then compress upward and inward with your fingers. Have the client exhale and holdyour hand in place as the client inhales a second time. With deep inhalation the edge of the liver is more easily palpated.To palpate by hooking, stand to the right of the client’s chest. Curl (hook) the fingers of both hands over the edge of theright costal margin. Ask the client to take a deep breath and gently but firmly pull inward and upward with your fingersNormal : - The liver is usually not palpable, although it may be felt in some thin clients. If the lower edge is felt, it should be firm,smooth, and even. Mild tenderness may be normal.

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Term
Spring
Professor
Smith
Tags
Peritoneum, Human abdomen, costal margin

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