Checklists for Clinical Nursing Skills

27

Name __________________________________________________________ Date ____________________________________ Course _________________________________________________________ Year ____________________________________ Instructor/examiner _ ____________________________________________ Position _ _______________________________

skill 2-7 Assessing the abdomen

Refer to Dempsey, Hillege and Hill, Fundamentals of Nursing and Midwifery: A Person-Centred Approach to Care 2e, Chapter 30, Comprehensive health assessment

Goal: The assessment is completed accurately without causing the patient to experience anxiety or discomfort, the findings are documented and the appropriate referral is made to other healthcare professionals, as needed, for further evaluation.  1. Identify the patient.  2. Check the medical order or clinical pathway/care plan.  3. Introduce yourself, explain the rationale for the procedure to the patient and family, and obtain consent.  4. Gather the necessary equipment. Equipment: stethoscope, alcohol wipes.  5. Undertake a risk assessment, if indicated.  6. Perform hand hygiene.  7. Put on personal protective equipment (PPE), if indicated.  8. Ensure patient privacy is maintained and that interruptions are minimal. Ensure adequate lighting.  9. Undertake a health history, as per Skill 2-1. 10. If possible, have the patient empty their bladder. Help the patient to undress, if needed, and provide a patient gown. Assist the patient to a supine position with the head slightly elevated and a pillow under the knees. Expose the abdomen. Use a blanket or drape to cover any exposed area other than the one being assessed. 11. Inspect the abdomen for skin colour, contour, peristalsis, pulsations and masses, and inspect the umbilicus and other surface characteristics (rashes, lesions, masses, scars). 12. Auscultate all four quadrants of the abdomen systematically for bowel sounds using the diaphragm of the stethoscope. 13. Auscultate the abdomen for vascular sounds using the bell of the stethoscope. 14. Percuss the abdomen for tones. 15. Palpate the abdomen lightly in all four quadrants and then use deep palpation. If the patient complains of pain or discomfort in a particular area of the abdomen, palpate that area last. 16. Palpate the kidneys on each side of the abdomen, the liver at the right costal border and the spleen at the left costal border.

Comments

Excellent

Satisfactory

Needs practice

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Copyright © 2014 by Wolters Kluwer Health | Lippincott Williams & Wilkins. Checklists for Clinical Nursing Skills by Louise Sparkes, Jennifer Bassett and Elisabeth Jacob.

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