The nurse is assessing the abdomen of the client with an undiagnosed disorder. In which sequence would the nurse conduct the abdominal assessment? (Use all options.)
A.
Palpation.
B.
Inspection.
C.
Auscultation.
D.
Percussion.
The Correct Answer and Explanation is:
For assessing the abdomen, the correct sequence for the nurse to follow is:
- Inspection (B)
- Auscultation (C)
- Percussion (D)
- Palpation (A)
Explanation:
- Inspection (B): The abdominal assessment begins with inspection. This step involves visually examining the abdomen for any abnormalities such as distention, discoloration, or visible masses. Observing the contour, symmetry, and any signs of skin changes (e.g., scars, rashes) provides initial clues about the client’s abdominal health.
- Auscultation (C): Next, the nurse performs auscultation. This step involves using a stethoscope to listen to the bowel sounds and vascular sounds in the abdomen. Auscultation is done before palpation and percussion because palpation and percussion can alter bowel sounds, making auscultation less accurate if performed afterward. Listening to bowel sounds helps assess gastrointestinal activity and identify any abnormal sounds such as hyperactive or hypoactive bowel sounds, which can be indicative of various conditions.
- Percussion (D): After auscultation, percussion is performed. Percussion involves tapping on the abdomen to assess the underlying structures based on the sounds produced. It helps determine the presence of fluid, gas, or masses. Percussion can provide information about organ size and the presence of abnormal fluid accumulation (e.g., ascites) or excessive gas.
- Palpation (A): Finally, the nurse conducts palpation. This involves gently pressing on the abdomen to assess tenderness, rigidity, and the presence of masses or organ enlargement. Palpation can reveal information about the texture and size of abdominal organs and detect any areas of discomfort or abnormal findings. Since palpation may alter bowel sounds and cause discomfort, it is best performed last to ensure an accurate assessment.
Following this sequence ensures a thorough and systematic evaluation of the abdomen, minimizing the risk of altering findings during the assessment process.