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Difficulty: HardTechniques of Physical Assessment

A 68-year-old client with a history of atherosclerosis and poorly controlled hypertension is admitted to the medical-surgical unit. The provider orders a comprehensive physical evaluation, with specific attention to the cardiovascular and gastrointestinal systems. Which nursing action demonstrates the appropriate application of physical assessment principles?

  1. Auscultating the epigastric and periumbilical regions with the bell of the stethoscope prior to initiating abdominal palpation.Answer
  2. B
    Performing light and deep palpation of all four abdominal quadrants to identify tenderness before auscultating for bowel activity.
  3. C
    Delegating the routine auscultation of bowel sounds to an experienced unlicensed assistive personnel (UAP) to focus on another critical client.
  4. D
    Documenting a newly auscultated abdominal bruit as an expected physiological change associated with the aging process.

Answer

The appropriate application of physical assessment principles is auscultating the epigastric and periumbilical regions with the bell of the stethoscope prior to initiating abdominal palpation.
The correct answer accurately combines two critical physical assessment principles. First, the abdominal assessment sequence strictly follows inspection, auscultation, percussion, and then palpation, preventing the mechanical stimulation of the bowel from altering normal sounds. Second, it identifies the bell of the stethoscope as the appropriate tool for detecting low-pitched vascular sounds, such as bruits, which are assessed in the epigastric and periumbilical areas.

Step-by-Step Solution

1
Determine the correct sequence for assessing the abdomen.
The correct sequence is inspect, auscultate, percuss, palpate.
Touching the abdomen through palpation or percussion can alter natural bowel motility and distort clinical findings.
2
Determine the correct stethoscope instrument for vascular sounds.
The bell of the stethoscope should be used.
Vascular bruits are low-pitched sounds, which are best detected using the bell.
3
Evaluate the clinical significance of a bruit.
A bruit is a pathological sign of turbulent blood flow, not a normal age-related change.
Clients with atherosclerosis and hypertension are at high risk for vascular disease, such as abdominal aortic aneurysms.
4
Apply delegation principles.
Assessments cannot be delegated to UAPs.
Auscultation and interpretation of findings require the clinical judgment of a licensed nurse.

Key Concept

Abdominal physical assessment sequence and stethoscope instrumentation
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Topics

Techniques of Physical Assessment

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