Abdomen

Surface Anatomy

4

locates and describes abdominal findings using two common methods of subdividing the abdomen: quadrants and regions.

4 Quadrants

Regions of the Abdomen

Epigastric: area between costal margins Umbilical: area around umbilicus Suprapubic or hypogastric: area above pubic

bone. or

RUQ LUQRLQ LLQ

Assessment of the abdomen

inspection, auscultation, palpation, and percussion.

Inspection first, followed by auscultation, Auscultation is done before palpation and percussion because palpation and percussion cause movement or

stimulation of the bowel, which can increase bowel motility and thus heighten

bowel sounds, creating false results. Ask the patient to breathe slowly and deeply through

the mouth during the examination to promote relaxation.

painful areas of the abdomen -assess at the end of the examination.

Use a warm stethoscope lighting - adequate hands - warm fingernails are trimmed short. supine position with the head slightly elevated and

arms at the sides. Place small pillows under the head and knees for

comfort.

Ask the client to urinate since an empty bladder makes the assessment more comfortable.

Ensure that the room is warm since the client will be exposed.

Health history

History of abdominal pain History of indigestion, nausea or vomiting,

constipation or diarrhea History of food allergies Appetite and usual food and fluid intake Usual bowel and bladder elimination patterns

History of gastrointestinal disorders, such aspeptic ulcer disease, bowel disease, gallbladder disease, liver disease,appendicitis

History of urinary tract disorders such as infections, kidney stones, or kidney disease

History of abdominal surgery or trauma Type and amount of prescribed and over-the-

counter medications used Amount and type of alcohol ingestion For women, menstrual history

Equipment

■ Examining light

■ Tape measure (metal or unstretchable cloth)

■ Skin-marking pen

■ Stethoscope

introduce self verify the client’s identity Explain to the client Perform hand hygiene Provide for client privacy.

Inquire about the following:

incidence of abdominal pain;

its location,

onset,

sequence, and

chronology;

its quality(description);

its frequency; associated symptoms (e.g., nausea, vomiting, diarrhea);

INSPECTION

INSPECTING THE ABDOMEN

Skin color and surface characteristics, umbilicus, contour, symmetry, peristalsis, pulsations, and visible masses.

The skin color may be slightly lighter than exposed areas.

Fine white or silver lines (striae) -weight gain or pregnancy.

The umbilicus should be centrally located and may be flat, rounded, or concave.

Observe the abdominal contour (line from the rib margin to the pubic bone)

Flat, rounded (convex), or scaphoid (concave)

Distended

Ask the client to take a deep breath and to hold it.

No evidence of enlargement of liver or spleen

Evidence of enlargement of liver or spleen

symmetry of contour - abdominal girth Asymmetric contour, e.g., Localized protrusions around umbilicus, hernia or tumor

The abdomen should be evenly rounded or symmetric, without visible peristalsis.

pulsation may normally be visible.

Observe the vascular pattern. No visible vascular pattern dilated veins is associated with liver disease, ascites,

and venocaval obstruction

Abnormal findings

swelling of the abdomen (ascites) and abdominal masses or unusual pulsations. Presence of rash or other lesions Tense, glistening skin (may indicate ascites,

edema) Purple striae (associated with Cushing’s disease

or rapid weight gain and loss)

AUSCULTATING BOWEL SOUNDS

ANDVASCULAR SOUNDS

Warm the hands and the stethoscope diaphragms.

Rationale: may cause the client to contract the abdominal muscles, and these contractions may be heard during auscultation

Audible bowel sounds

DEVIATIONS FROM NORMAL

Hypoactive, i.e., extremely soft andinfrequent (e.g., one per minute).

indicate decreased motility (surgery, inflammation, paralytic ileus, or late bowel obstruction.)

Hyperactive/increased, i.e., highpitched, loud, rushing sounds that occur frequently (e.g., every 3 seconds) also known as borborygmi.

indicate increasednintestinal motility (diarrhea, an early bowel obstruction, or the use of laxatives.)

True absence of sounds (none heard in 3 to 5 minutes)

indicates a cessation of intestinal motility.

For Bowel Sounds

Use the diaphragm. Place diaphragm of the stethoscope in each of the

four quadrants Listen for active bowel sounds—irregular gurgling

noises occurring about every 5 to 20 seconds.

Before documenting bowel sounds as absent, the nurse must listen for 2 minutes or longer in each abdominal quadrant.

For Vascular Sounds

Use the bell of the stethoscope over the aorta, renal arteries, iliac arteries, and femoral arteries.

Listen for bruits.

Absence of arterial bruits

Loud bruit over aortic area (possiblen aneurysm) Bruit over renal or iliac arteries

Peritoneal Friction Rubs

Friction rubs may be caused by inflammation, infection, or abnormal growths.

Absence of friction rub

Friction rub

Percussion of the Abdomen

Percuss several areas in each of the four quadrants to determine presence of tympany (gas in stomach

and intestines) and Dullness (decrease, absence, or flatness of

resonance over solid masses or fluid).

Use a systematic pattern:

Begin in the lower right quadrant, proceed to the upper right quadrant, the upper left quadrant, and the lower left quadrant.

NORMAL FINDINGS

Tympany over the stomach and gas-filled bowels; dullness, especially over the liver and spleen, or a

full bladder

DEVIATIONS FROM NORMAL

Large dull areas (associated with presence of fluid or a tumor)

Palpation of the Abdomen

Watch the patient’s face for nonverbal signs of pain during palpation.

Palpate each quadrant in a systematic manner, noting muscular resistance, tenderness, enlargement of the organs, or masses.

If the patient complains of abdominal pain, palpate the area of pain last.

The abdomen should normally be soft, relaxed, and free of tenderness.

Abnormal findings include involuntary rigidity, spasm, and pain

may indicate trauma, peritonitis, infection, tumors, or enlarged or diseased abdominal organs.

PALPATING THE LIVER Palpate the liver by placing the left hand under

the patients lower right rib cage

Palpate gently inward & upward with fingertips while patient takes a deep breath

The normal liver edge should feel firm and smooth and may be mildly tender.

Abnormal findings include Hard and firm liver edge (found in cancer of the liver), Nodularity (found with tumor, metastatic cancer,

cirrhosis of the liver), and pain (from vascular engorgement as in congestive heart

failure, hepatitis, or abscess).

Spleen: Left hand – left lower rib cage Press right hand below the left costal margin-

while patient takes deep breath

Not palpable

KIDNEY: Usually felt in people with very relaxed abdominal

muscles Solid, firm, smooth elastic mass

Palpation of the Bladder Palpate the area above the pubic symphysis if the

client’s history indicates possible urinary retention.

Not palpable

Distended and palpable as smooth, round, tense mass (indicates urinary retention)

Aorta: With thumb and index finger Press deeply in the epigastric region

Soft & pulsatile

Normal Age-Related Variations

INFANTS Internal organs of newborns and infants are

proportionately larger than those of older children and adults

The infant’s liver may be palpable Umbilical hernias may be present at birth.

CHILDREN Toddlers -“pot belly” appearance, Late preschool and school-age -leaner and have a

flat abdomen. Peristaltic waves may be more visible than in

adults. The liver is relatively larger than in adults.

OLDER ADULTS Decreased bowel sounds Decreased abdominal tone Liver border palpated more easily The rounded abdomens -increase in adipose tissue

and a decrease in muscle tone. Stool passes through the intestines at a slower rate

GI Variations with pregnancy

Decrease in gastric motility High incidence of N, V (r/t pregnancy hormones)

and “heartburn” or acid reflux Bowel sounds diminished r/t enlarged uterus

displacing intestines Linea nigra- increased pigmentation of abd midline Striae Gravidarum

Sample Documentation

Normal Exam-

Abdomen soft, rounded and symmetric without distention; no lesions or scars, or visible peristalsis. Aorta midline without bruit or visible pulsation; umbilicus inverted and midline without herniation; bowel sounds present in all 4 quadrants. Liver, kidney and spleen non-palpable; no tenderness on palpation. Reports good appetite; no constipation, nausea or diarrhea. Voiding well and denies laxative use.

Normal Examination findings…

I examined this elderly gentleman’s abdomen. On general inspection from the end of the bed he appeared comfortable at rest. There were no peripheral signs of abdominal or liver disease. His abdomen was soft and non-tender with no distension. There were no palpable masses or organomegaly. Bowel sounds were present.

In summary, this is an elderly gentleman with normal abdominal examination.