Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of...

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of Elsevier Inc.

AbdomenAbdomen

Chapter 21Chapter 21


Chapter 21: AbdomenChapter 21: Abdomen

AbdomenAbdomen

Abdomen is a large oval cavity extending from Abdomen is a large oval cavity extending from diaphragm down to brim of pelvisdiaphragm down to brim of pelvis• It is bordered in back by vertebral column and It is bordered in back by vertebral column and

paravertebral muscles and at sides and front by lower rib paravertebral muscles and at sides and front by lower rib cage and abdominal musclescage and abdominal muscles

• Four layers of large, flat muscles form ventral abdominal Four layers of large, flat muscles form ventral abdominal wallwall

• These are joined at midline by a tendinous seam, the These are joined at midline by a tendinous seam, the linea albalinea alba

• One set, rectus abdominis, forms a strip extending length One set, rectus abdominis, forms a strip extending length of midline, and its edge is often palpableof midline, and its edge is often palpable

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Structure and FunctionStructure and Function

Internal anatomyInternal anatomy Inside abdominal cavity, all internal organs are Inside abdominal cavity, all internal organs are

called visceracalled viscera• Important to know location of these organs so well that Important to know location of these organs so well that

you could draw a map of them on skin you could draw a map of them on skin

• You must be able to visualize each organ that you listen You must be able to visualize each organ that you listen to or palpate through abdominal wallto or palpate through abdominal wall

• Solid viscera are those that maintain a characteristic Solid viscera are those that maintain a characteristic shape: liver, pancreas, spleen, adrenal glands, kidneys, shape: liver, pancreas, spleen, adrenal glands, kidneys, ovaries, and uterusovaries, and uterus

• Liver fills most of right upper quadrant (RUQ) and Liver fills most of right upper quadrant (RUQ) and extends over to left midclavicular lineextends over to left midclavicular line

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Structure and FunctionStructure and Function (cont.)(cont.)

Internal anatomy (cont.)Internal anatomy (cont.) Lower edge of liver and right kidney may normally Lower edge of liver and right kidney may normally

be palpablebe palpable• Ovaries normally palpable only on bimanual examination Ovaries normally palpable only on bimanual examination

during pelvic examinationduring pelvic examination

• Shape of hollow viscera, such as stomach, gallbladder, Shape of hollow viscera, such as stomach, gallbladder, small intestine, colon, and bladder depends on contentssmall intestine, colon, and bladder depends on contents

Usually are not palpable, although you may feel a colon Usually are not palpable, although you may feel a colon distended with feces or a bladder distended with urinedistended with feces or a bladder distended with urine

• Stomach just below diaphragm, between liver and spleenStomach just below diaphragm, between liver and spleen

• Gallbladder rests under posterior surface of liver, just Gallbladder rests under posterior surface of liver, just lateral to right midclavicular linelateral to right midclavicular line

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Internal anatomy (cont.)Internal anatomy (cont.) Note that small intestine located in all four quadrantsNote that small intestine located in all four quadrants

• Extends from stomach’s pyloric valve to ileocecal valve in Extends from stomach’s pyloric valve to ileocecal valve in right lower quadrant (RLQ), where it joins colonright lower quadrant (RLQ), where it joins colon

Spleen is soft mass of lymphatic tissue on Spleen is soft mass of lymphatic tissue on posterolateral wall of abdominal cavity, immediately posterolateral wall of abdominal cavity, immediately under diaphragm under diaphragm • Lies obliquely with its long axis behind and parallel to tenth Lies obliquely with its long axis behind and parallel to tenth

rib, lateral to midaxillary linerib, lateral to midaxillary line

• Width extends from ninth to eleventh rib, about 7 cmWidth extends from ninth to eleventh rib, about 7 cm Not palpable normally; if it becomes enlarged, its lower pole Not palpable normally; if it becomes enlarged, its lower pole

moves downward and toward midlinemoves downward and toward midline

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Internal anatomy (cont.)Internal anatomy (cont.) Aorta just to left of midline in upper part of Aorta just to left of midline in upper part of

abdomenabdomen• Descends behind peritoneum, and at 2 cm below Descends behind peritoneum, and at 2 cm below

umbilicus it bifurcates into right and left common iliac umbilicus it bifurcates into right and left common iliac arteries opposite fourth lumbar vertebraarteries opposite fourth lumbar vertebra

Palpate aortic pulsations easily in upper anterior abdominal Palpate aortic pulsations easily in upper anterior abdominal wallwall

• Right and left iliac arteries become femoral arteries in Right and left iliac arteries become femoral arteries in groin areagroin area

Pulsations easily palpated at point halfway between Pulsations easily palpated at point halfway between anterior superior iliac spine and symphysis pubisanterior superior iliac spine and symphysis pubis

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Internal anatomy (cont.)Internal anatomy (cont.) Pancreas is a soft, lobulated gland located behind Pancreas is a soft, lobulated gland located behind

stomachstomach• Stretches obliquely across posterior abdominal wall to Stretches obliquely across posterior abdominal wall to

left upper quadrantleft upper quadrant

Bean-shaped kidneys are retroperitoneal, or Bean-shaped kidneys are retroperitoneal, or posterior to abdominal contentsposterior to abdominal contents• They are well protected by posterior ribs and They are well protected by posterior ribs and

musculaturemusculature

• Twelfth rib forms angle with vertebral column, Twelfth rib forms angle with vertebral column, costovertebral angle; left kidney lies here at eleventh and costovertebral angle; left kidney lies here at eleventh and twelfth ribstwelfth ribs

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Internal anatomy (cont.)Internal anatomy (cont.) Because of placement of liver, right kidney rests Because of placement of liver, right kidney rests

1 to 2 cm lower than left kidney1 to 2 cm lower than left kidney For convenience in description, abdominal wall is For convenience in description, abdominal wall is

divided into four quadrants by a vertical and a divided into four quadrants by a vertical and a horizontal line bisecting umbilicushorizontal line bisecting umbilicus

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Internal AnatomyInternal Anatomy

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Deep Internal AnatomyDeep Internal Anatomy

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RUQRUQ LiverLiver GallbladderGallbladder DuodenumDuodenum Head of pancreasHead of pancreas Right kidney and Right kidney and

adrenal glandadrenal gland Hepatic flexure of colonHepatic flexure of colon Part of ascending and Part of ascending and

transverse colontransverse colon

LUQLUQ StomachStomach SpleenSpleen Left lobe of liverLeft lobe of liver Body of pancreasBody of pancreas Left kidney and adrenal Left kidney and adrenal

glandgland Splenic flexure of colonSplenic flexure of colon Part of transverse and Part of transverse and

descending colondescending colon

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Right lower quadrantRight lower quadrant

(RLQ)(RLQ) CecumCecum AppendixAppendix Right ovary and tubeRight ovary and tube Right ureterRight ureter Right spermatic cordRight spermatic cord

Left lower quadrantLeft lower quadrant

(LLQ)(LLQ) Part of descending Part of descending

coloncolon Sigmoid colonSigmoid colon Left ovary and tubeLeft ovary and tube Left ureterLeft ureter Left spermatic cordLeft spermatic cord

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MidlineMidline AortaAorta Uterus, if enlargedUterus, if enlarged Bladder, if distendedBladder, if distended

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QuadrantsQuadrants

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Structure and Function:Structure and Function:Developmental CompetenceDevelopmental Competence

Infants and childrenInfants and children In newborn, umbilical cord shows prominently on In newborn, umbilical cord shows prominently on

abdomenabdomen• Contains two arteries and one veinContains two arteries and one vein

• Liver takes up proportionately more space in abdomen at Liver takes up proportionately more space in abdomen at birth than in later lifebirth than in later life

• In healthy term neonates, lower edge may be palpated In healthy term neonates, lower edge may be palpated 0.5 to 2.5 cm below right costal margin0.5 to 2.5 cm below right costal margin

• Urinary bladder located higher in abdomen than in adult Urinary bladder located higher in abdomen than in adult

• Lies between symphysis and umbilicusLies between symphysis and umbilicus

• During early childhood abdominal wall less muscular, so During early childhood abdominal wall less muscular, so organs may be easier to palpateorgans may be easier to palpate

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(cont.)(cont.) Pregnant womanPregnant woman

Nausea and vomiting, or “morning sickness,” is Nausea and vomiting, or “morning sickness,” is early sign of pregnancy for most pregnant women, early sign of pregnancy for most pregnant women, starting between first and second missed periodsstarting between first and second missed periods• Cause unknown; may be due to hormone changes, such Cause unknown; may be due to hormone changes, such

as production of human chorionic gonadotropin (hCG)as production of human chorionic gonadotropin (hCG)

• Another symptom is “acid indigestion” or heartburn Another symptom is “acid indigestion” or heartburn (pyrosis) caused by esophageal reflux(pyrosis) caused by esophageal reflux

• Gastrointestinal motility decreases, which prolongs Gastrointestinal motility decreases, which prolongs gastric emptying timegastric emptying time

• Decreased motility causes more water to be reabsorbed Decreased motility causes more water to be reabsorbed from colon, which leads to constipationfrom colon, which leads to constipation

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(cont.)(cont.) Pregnant woman (cont.)Pregnant woman (cont.)

Constipation and increased venous pressure in Constipation and increased venous pressure in lower pelvis may lead to hemorrhoidslower pelvis may lead to hemorrhoids• Enlarging uterus displaces intestines upward and Enlarging uterus displaces intestines upward and

posteriorlyposteriorly

• Bowel sounds are diminishedBowel sounds are diminished

• Appendix displaced upward and to rightAppendix displaced upward and to right

• Skin changes on abdomen include striae and linea nigraSkin changes on abdomen include striae and linea nigra

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(cont.)(cont.) Aging adultAging adult

Aging alters appearance of abdominal wallAging alters appearance of abdominal wall• During and after middle age, some fat accumulates in During and after middle age, some fat accumulates in

suprapubic area in females as a result of decreased suprapubic area in females as a result of decreased estrogen levelsestrogen levels

• Males also show some fat deposits in abdominal area, Males also show some fat deposits in abdominal area, resulting in “spare tire”resulting in “spare tire”

This accentuates in adults with a more sedentary lifestyleThis accentuates in adults with a more sedentary lifestyle

• With further aging, adipose tissue redistributed away With further aging, adipose tissue redistributed away from face and extremities and to abdomen and hipsfrom face and extremities and to abdomen and hips

• Abdominal musculature relaxesAbdominal musculature relaxes

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(cont.)(cont.) Aging adult (cont.)Aging adult (cont.)

Changes of aging occur in gastrointestinal system Changes of aging occur in gastrointestinal system but do not significantly affect function when no but do not significantly affect function when no disease is presentdisease is present• Salivation decreases, causing a dry mouth and a Salivation decreases, causing a dry mouth and a

decreased sense of tastedecreased sense of taste

• Esophageal emptying is delayed; if an aging person is Esophageal emptying is delayed; if an aging person is fed in supine position, this increases risk of aspirationfed in supine position, this increases risk of aspiration

• Gastric acid secretion decreases with aging; may cause Gastric acid secretion decreases with aging; may cause pernicious anemia (because it interferes with vitamin B12 pernicious anemia (because it interferes with vitamin B12 absorption), iron deficiency anemia, and malabsorption absorption), iron deficiency anemia, and malabsorption of calciumof calcium

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Incidence of gallstones increases with age, Incidence of gallstones increases with age, • Occurs in 10% to 20% of middle-aged and older adults; Occurs in 10% to 20% of middle-aged and older adults;

more common in femalesmore common in females

• Liver size decreases with age, particularly after 80 years, Liver size decreases with age, particularly after 80 years, although most liver function remains normalalthough most liver function remains normal

• Drug metabolism by liver is impaired, in part because by Drug metabolism by liver is impaired, in part because by age 60 to 80 years blood flow through liver is decreased age 60 to 80 years blood flow through liver is decreased

• Therefore, liver metabolism that is responsible for Therefore, liver metabolism that is responsible for enzymatic oxidation, reduction, and hydrolysis of drugs is enzymatic oxidation, reduction, and hydrolysis of drugs is substantially decreased with agesubstantially decreased with age

• Prolonged liver metabolism causes increased side Prolonged liver metabolism causes increased side effectseffects

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Aging persons frequently report constipationAging persons frequently report constipation• However, a greater number use laxatives regularly than However, a greater number use laxatives regularly than

actually are constipatedactually are constipated

• This is due to concern about how often healthy person This is due to concern about how often healthy person should defecate (true constipation is less often than should defecate (true constipation is less often than every 3rd day) and confusing passage of hard or small every 3rd day) and confusing passage of hard or small stools, feeling of incomplete evacuation, or need to strain stools, feeling of incomplete evacuation, or need to strain at stool for constipationat stool for constipation

• Of those aging people who actually are constipated, two Of those aging people who actually are constipated, two thirds have slowed passage in distal colon and delayed thirds have slowed passage in distal colon and delayed rectal emptyingrectal emptying

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Common causes of constipation include Common causes of constipation include • Decreased physical activityDecreased physical activity

• Inadequate intake of waterInadequate intake of water

• Low-fiber dietLow-fiber diet

• Side effects of medicationsSide effects of medications

• Irritable bowel syndromeIrritable bowel syndrome

• Bowel obstructionBowel obstruction

• HypothyroidismHypothyroidism

• Inadequate toilet facilities, i.e., difficulty ambulating to Inadequate toilet facilities, i.e., difficulty ambulating to toilet may cause person to deliberately retain stool until it toilet may cause person to deliberately retain stool until it becomes hard and difficult to passbecomes hard and difficult to pass

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Structure and Function:Structure and Function:Cultural CompetenceCultural Competence

Lactase is digestive enzyme necessary for Lactase is digestive enzyme necessary for absorption of carbohydrate lactose (milk sugar)absorption of carbohydrate lactose (milk sugar)• In some racial groups, lactase activity is high at birth but In some racial groups, lactase activity is high at birth but

declines to low levels by adulthooddeclines to low levels by adulthood These people are lactose intolerant and have abdominal These people are lactose intolerant and have abdominal

pain, bloating, and flatulence when milk products are pain, bloating, and flatulence when milk products are consumedconsumed

• Incidence of lactose intolerance is Incidence of lactose intolerance is 70% to 90% in African Americans, American Indians, 70% to 90% in African Americans, American Indians,

Asians, and Mediterranean groupsAsians, and Mediterranean groups However, in Europeans and Americans of northern and However, in Europeans and Americans of northern and

western European descent, lactase activity remains high western European descent, lactase activity remains high through adulthood, and incidence of milk intolerance is only through adulthood, and incidence of milk intolerance is only about 15%about 15%

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Subjective DataSubjective Data

AppetiteAppetite DysphagiaDysphagia Food intoleranceFood intolerance Abdominal painAbdominal pain Nausea and vomitingNausea and vomiting Bowel habitsBowel habits Abdominal historyAbdominal history MedicationsMedications

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Subjective DataSubjective Data (cont.)(cont.)

AppetiteAppetite Any change in appetite? Is this a loss of appetite?Any change in appetite? Is this a loss of appetite? Any change in weight? How much weight gained Any change in weight? How much weight gained

or lost? Over what time period? Is the weight loss or lost? Over what time period? Is the weight loss due to diet?due to diet?

DysphagiaDysphagia Any difficulty swallowing? When did you first Any difficulty swallowing? When did you first

notice this?notice this?

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Food intoleranceFood intolerance Are there any foods you cannot eat? What Are there any foods you cannot eat? What

happens if you do eat them: allergic reaction, happens if you do eat them: allergic reaction, heartburn, belching, bloating, or indigestion?heartburn, belching, bloating, or indigestion?

Do you use antacids? How often?Do you use antacids? How often?

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Abdominal painAbdominal pain Any abdominal pain? Please point to it.Any abdominal pain? Please point to it.

• Is pain in one spot or does it move around?Is pain in one spot or does it move around?

• How did it start? How long have you had it?How did it start? How long have you had it?

• Is it constant, or does it come and go? Does it occur Is it constant, or does it come and go? Does it occur before or after meals? Does it peak? When?before or after meals? Does it peak? When?

• How would you describe the character of the pain: How would you describe the character of the pain: cramping (colic type), burning in pit of stomach, dull, cramping (colic type), burning in pit of stomach, dull, stabbing, or aching?stabbing, or aching?

• Is pain relieved by food, or worse after eating?Is pain relieved by food, or worse after eating?

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Abdominal pain (cont.) Abdominal pain (cont.) Is pain associated with menstrual period or Is pain associated with menstrual period or

irregularities, stress, dietary indiscretion, fatigue, irregularities, stress, dietary indiscretion, fatigue, nausea and vomiting, gas, fever, rectal bleeding, nausea and vomiting, gas, fever, rectal bleeding, frequent urination, or vaginal or penile discharge?frequent urination, or vaginal or penile discharge?• What makes the pain worse: food, position, stress, What makes the pain worse: food, position, stress,

medication, or activity?medication, or activity?

• What have you tried to relieve pain by resting, using a What have you tried to relieve pain by resting, using a heating pad, changing position, or taking medication?heating pad, changing position, or taking medication?

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Nausea and vomitingNausea and vomiting Any nausea or vomiting? Any nausea or vomiting?

• How often? How much comes up? What is the color? Is How often? How much comes up? What is the color? Is there an odor?there an odor?

• Is it bloody?Is it bloody?

• Is nausea and vomiting associated with colicky pain, Is nausea and vomiting associated with colicky pain, diarrhea, fever, or chills?diarrhea, fever, or chills?

• What foods did you eat in last 24 hours? Where did you What foods did you eat in last 24 hours? Where did you eat? At home, school, restaurant? Is there anyone else eat? At home, school, restaurant? Is there anyone else in family with same symptoms in last 24 hours?in family with same symptoms in last 24 hours?

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Bowel habitsBowel habits How often do you have a bowel movement?How often do you have a bowel movement?

• What is the color and consistency?What is the color and consistency?

• Any diarrhea or constipation? How long?Any diarrhea or constipation? How long?

• Any recent change in bowel habits?Any recent change in bowel habits?

• Use laxatives? Which ones? How often do you use Use laxatives? Which ones? How often do you use them?them?

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Abdominal historyAbdominal history Any history of gastrointestinal problems such as Any history of gastrointestinal problems such as

ulcer, gallbladder disease, hepatitis/jaundice, ulcer, gallbladder disease, hepatitis/jaundice, appendicitis, colitis, or hernia?appendicitis, colitis, or hernia?• Ever had any operations in abdomen? Please describe.Ever had any operations in abdomen? Please describe.

• Any problems after surgery?Any problems after surgery?

• Any abdominal x-ray studies? What were results?Any abdominal x-ray studies? What were results?

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MedicationsMedications What medications are you currently taking?What medications are you currently taking? How much alcohol do you drink each day? Each How much alcohol do you drink each day? Each

week? When was your last alcoholic drink?week? When was your last alcoholic drink? Do you smoke? How many packs per day? For Do you smoke? How many packs per day? For

how long?how long? Nutritional assessmentNutritional assessment

Now I would like to ask you about your dietNow I would like to ask you about your diet• Please tell me all food you ate yesterday, starting with Please tell me all food you ate yesterday, starting with

breakfastbreakfast

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Subjective DataSubjective Data (cont.)(cont.) Additional history for infants and childrenAdditional history for infants and children

Are you breastfeeding or bottle-feeding your infant? If Are you breastfeeding or bottle-feeding your infant? If bottle-feeding, how does infant tolerate formula? bottle-feeding, how does infant tolerate formula?

How does infant tolerate new foods?How does infant tolerate new foods? How often does your toddler/child eat? Does he or How often does your toddler/child eat? Does he or

she eat regular meals? How do you feel about your she eat regular meals? How do you feel about your child’s eating problems?child’s eating problems?• Please describe all that your child had to eat yesterday, Please describe all that your child had to eat yesterday,

starting with breakfast; what foods does child eat for snacks?starting with breakfast; what foods does child eat for snacks?

• Does toddler/child ever eat nonfoods, such as grass, dirt, or Does toddler/child ever eat nonfoods, such as grass, dirt, or paint chips?paint chips?

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Subjective DataSubjective Data (cont.)(cont.) Additional history for infants and children (cont.)Additional history for infants and children (cont.)

Does your child have constipation? If so, for how Does your child have constipation? If so, for how long?long?

What are number of stools per day? Stools per week?What are number of stools per day? Stools per week? How much water and juice is in child’s diet?How much water and juice is in child’s diet? Does the constipation seem to be associated with Does the constipation seem to be associated with

toilet training?toilet training? What have you tried to treat constipation?What have you tried to treat constipation? Does child have abdominal pain? Please describe Does child have abdominal pain? Please describe

what you have noticed and when it started.what you have noticed and when it started.

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Additional history for infants and children Additional history for infants and children (cont.)(cont.) For overweight child: How long has weight been a For overweight child: How long has weight been a

problem?problem?• At what age did child first seem overweight? Did any At what age did child first seem overweight? Did any

change in diet pattern occur then?change in diet pattern occur then?

• Describe diet pattern now.Describe diet pattern now.

• Do any others in family have similar problem?Do any others in family have similar problem?

• How does child feel about his or her weight?How does child feel about his or her weight?

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Additional history for adolescentsAdditional history for adolescents What do you eat at regular meals? Do you eat What do you eat at regular meals? Do you eat

breakfast? What do you eat for snacks?breakfast? What do you eat for snacks?• How many calories do you consume?How many calories do you consume?

• What is your exercise pattern?What is your exercise pattern?

• If weight is less than body requirements: How much have If weight is less than body requirements: How much have you lost? By diet, exercise, or other means?you lost? By diet, exercise, or other means?

How do you feel? Tired, hungry? How do you think your How do you feel? Tired, hungry? How do you think your body looks?body looks?

What is your activity pattern?What is your activity pattern? Is weight loss associated with any other body change, such Is weight loss associated with any other body change, such

as menstrual irregularity?as menstrual irregularity? What do your parents and friends say about your eating?What do your parents and friends say about your eating?

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Additional history for aging adultsAdditional history for aging adults How do you acquire your groceries and prepare How do you acquire your groceries and prepare

your meals?your meals?• Do you eat alone or do you share meals with others?Do you eat alone or do you share meals with others?

Please tell me all that you had to eat yesterday, Please tell me all that you had to eat yesterday, starting with breakfast.starting with breakfast.• Do you have any trouble swallowing these foods?Do you have any trouble swallowing these foods?

• What do you do right after eating, such as walking or What do you do right after eating, such as walking or taking a nap?taking a nap?

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Additional history for aging adults (cont.)Additional history for aging adults (cont.) How often do your bowels move?How often do your bowels move?

• If person reports constipation: What do you mean by If person reports constipation: What do you mean by constipation? How much liquid is in your diet? How much constipation? How much liquid is in your diet? How much bulk or fiber?bulk or fiber?

• Do you take anything for constipation, such as laxatives? Do you take anything for constipation, such as laxatives? Which ones? How often?Which ones? How often?

• What medications do you take?What medications do you take?

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Objective DataObjective Data (cont.)(cont.)

PreparationPreparation Lighting should include a strong overhead light Lighting should include a strong overhead light

and a secondary stand lightand a secondary stand light Expose abdomen so that it is fully visible; drape Expose abdomen so that it is fully visible; drape

genitalia and female breastsgenitalia and female breasts

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Preparation (cont.)Preparation (cont.) Following measures will enhance abdominal wall Following measures will enhance abdominal wall

relaxationrelaxation• Person should have emptied bladder, saving urine Person should have emptied bladder, saving urine

specimen if neededspecimen if needed

• Keep room warm to avoid chilling and tensing of musclesKeep room warm to avoid chilling and tensing of muscles

• Position person supine, with head on pillow, knees bent Position person supine, with head on pillow, knees bent or on pillow, and arms at sides or across chestor on pillow, and arms at sides or across chest

• Note: Discourage person from placing his or her arms Note: Discourage person from placing his or her arms over head because this tenses abdominal musculatureover head because this tenses abdominal musculature

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PreparationPreparation (cont.)(cont.) Following measures will enhance abdominal wall Following measures will enhance abdominal wall

relaxation (cont.)relaxation (cont.)• To avoid abdominal tensing, stethoscope endpiece must To avoid abdominal tensing, stethoscope endpiece must

be warm, your hands must be warm, and your fingernails be warm, your hands must be warm, and your fingernails must be very shortmust be very short

• Inquire about any painful areas; examine such an area Inquire about any painful areas; examine such an area last to avoid any muscle guardinglast to avoid any muscle guarding

• Finally, learn to use distraction: enhance muscle Finally, learn to use distraction: enhance muscle relaxation through breathing exercises; emotive imagery; relaxation through breathing exercises; emotive imagery; your low, soothing voice; and person relating his or her your low, soothing voice; and person relating his or her abdominal history while you palpateabdominal history while you palpate

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Equipment neededEquipment needed StethoscopeStethoscope Small centimeter rulerSmall centimeter ruler Skin-marking penSkin-marking pen Alcohol wipe to clean endpieceAlcohol wipe to clean endpiece

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Inspect the abdomenInspect the abdomen ContourContour

• Stand on person’s right side and look down on abdomenStand on person’s right side and look down on abdomen

• Then stoop or sit to gaze across abdomenThen stoop or sit to gaze across abdomen

• Your head should be slightly higher than abdomen Your head should be slightly higher than abdomen

• Determine profile from rib margin to pubic bone; contour Determine profile from rib margin to pubic bone; contour describes nutritional state and normally ranges from flat describes nutritional state and normally ranges from flat to roundedto rounded

SymmetrySymmetry• Shine a light across abdomen toward you, or shine it Shine a light across abdomen toward you, or shine it

lengthwise across the personlengthwise across the person

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ContourContour

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Inspect the abdomenInspect the abdomen (cont.)(cont.) Symmetry (cont.)Symmetry (cont.)

• Abdomen should be symmetric bilaterallyAbdomen should be symmetric bilaterally

• Note any localized bulging, visible mass, or asymmetric Note any localized bulging, visible mass, or asymmetric shapeshape

• Even small bulges highlighted by shadowEven small bulges highlighted by shadow

• Step to foot of examination table to recheck symmetryStep to foot of examination table to recheck symmetry

• Ask person to take a deep breath to further highlight any Ask person to take a deep breath to further highlight any changechange

• Abdomen should stay smooth and symmetricAbdomen should stay smooth and symmetric Or ask person to perform a sit-up without pushing up with Or ask person to perform a sit-up without pushing up with

his or her handshis or her hands

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Inspect the abdomen (cont.)Inspect the abdomen (cont.) UmbilicusUmbilicus

• Normally it is midline and inverted, with no sign of Normally it is midline and inverted, with no sign of discoloration, inflammation, or herniadiscoloration, inflammation, or hernia

• Becomes everted and pushed upward with pregnancyBecomes everted and pushed upward with pregnancy

• Umbilicus is common site for piercings in young women; Umbilicus is common site for piercings in young women; site should not be red or crustedsite should not be red or crusted

SkinSkin• Surface smooth and even, with homogeneous color; Surface smooth and even, with homogeneous color;

good area to judge pigment because often protected good area to judge pigment because often protected from sunfrom sun

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Inspect the abdomenInspect the abdomen (cont.)(cont.) Skin (cont.)Skin (cont.)

• One common pigment change is striae, silvery white, One common pigment change is striae, silvery white, linear, jagged marks about 1 to 6 cm longlinear, jagged marks about 1 to 6 cm long

• Occur when elastic fibers in reticular layer of skin are Occur when elastic fibers in reticular layer of skin are broken after rapid or prolonged stretching, as in broken after rapid or prolonged stretching, as in pregnancy or excessive weight gain; recent striae are pregnancy or excessive weight gain; recent striae are pink or blue; then they turn silvery whitepink or blue; then they turn silvery white

• Pigmented nevi (moles), circumscribed brown macular or Pigmented nevi (moles), circumscribed brown macular or papular areas, common on abdomenpapular areas, common on abdomen

• Normally, no lesions are present, although you may note Normally, no lesions are present, although you may note well-healed surgical scarswell-healed surgical scars

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Inspect the abdomenInspect the abdomen (cont.)(cont.) Skin (cont.)Skin (cont.)

• If a scar present, draw its location in person’s record, If a scar present, draw its location in person’s record, indicating length in centimetersindicating length in centimeters

• Occasionally a person forgets about an operation while Occasionally a person forgets about an operation while providing the history; if you note a scar now, ask about itproviding the history; if you note a scar now, ask about it

• Surgical scar alerts you to possible presence of Surgical scar alerts you to possible presence of underlying adhesions and excess fibrous tissueunderlying adhesions and excess fibrous tissue

• Fine venous network may be visible in thin personsFine venous network may be visible in thin persons

• Good skin turgor reflects healthy nutrition; gently pinch Good skin turgor reflects healthy nutrition; gently pinch up a fold of skin; then release to note skin’s immediate up a fold of skin; then release to note skin’s immediate return to original positionreturn to original position

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Inspect the abdomen (cont.)Inspect the abdomen (cont.) Pulsation or movementPulsation or movement

• Normally, you may see pulsations from aorta beneath Normally, you may see pulsations from aorta beneath skin in epigastric area, particularly in thin persons with skin in epigastric area, particularly in thin persons with good muscle wall relaxationgood muscle wall relaxation

• Respiratory movement also shows in abdomen, Respiratory movement also shows in abdomen, particularly in malesparticularly in males

• Finally, waves of peristalsis sometimes are visible in very Finally, waves of peristalsis sometimes are visible in very thin persons; they ripple slowly and obliquely across thin persons; they ripple slowly and obliquely across abdomenabdomen

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Inspect the abdomen (cont.)Inspect the abdomen (cont.) Hair distributionHair distribution

• Pattern of pubic hair growth normally has diamond shape Pattern of pubic hair growth normally has diamond shape in adult males and an inverted triangle shape in adult in adult males and an inverted triangle shape in adult femalesfemales

DemeanorDemeanor• Comfortable person is relaxed quietly on examining table Comfortable person is relaxed quietly on examining table

and has a benign facial expression and slow, even and has a benign facial expression and slow, even respirationsrespirations

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Auscultate bowel sounds and vascular Auscultate bowel sounds and vascular soundssounds This is done because percussion and palpation This is done because percussion and palpation

can increase peristalsis, which would give a false can increase peristalsis, which would give a false interpretation of bowel soundsinterpretation of bowel sounds• Use diaphragm endpiece because bowel sounds are Use diaphragm endpiece because bowel sounds are

relatively high pitchedrelatively high pitched

• Hold stethoscope lightly against skin; pushing too hard Hold stethoscope lightly against skin; pushing too hard may stimulate more bowel soundsmay stimulate more bowel sounds

• Begin in RLQ at ileocecal valve area because bowel Begin in RLQ at ileocecal valve area because bowel sounds are normally always present heresounds are normally always present here

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Auscultate bowel sounds and vascular Auscultate bowel sounds and vascular sounds (cont.)sounds (cont.) Bowel soundsBowel sounds

• Note character and frequency of bowel soundsNote character and frequency of bowel sounds

• Bowel sounds originate from movement of air and fluid Bowel sounds originate from movement of air and fluid through small intestinethrough small intestine

• Depending on time elapsed since eating, a wide range of Depending on time elapsed since eating, a wide range of normal sounds can occurnormal sounds can occur

• Bowel sounds are high pitched, gurgling, cascading Bowel sounds are high pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5 to 30 sounds, occurring irregularly anywhere from 5 to 30 times per minute; do not bother to count themtimes per minute; do not bother to count them

• Judge if they are normal, hypoactive, or hyperactiveJudge if they are normal, hypoactive, or hyperactive

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Auscultate bowel sounds and vascular Auscultate bowel sounds and vascular soundssounds (cont.)(cont.) Bowel sounds (cont.)Bowel sounds (cont.)

• One type of hyperactive bowel sound is fairly common One type of hyperactive bowel sound is fairly common This is the hyperperistalsis when you feel your “stomach This is the hyperperistalsis when you feel your “stomach

growling,” termed borborygmusgrowling,” termed borborygmus

• Perfectly “silent abdomen” is uncommon; you must listen Perfectly “silent abdomen” is uncommon; you must listen for 5 minutes by your watch before deciding bowel for 5 minutes by your watch before deciding bowel sounds are completely absentsounds are completely absent

Slide 21-53




Auscultate bowel sounds and vascular Auscultate bowel sounds and vascular sounds (cont.)sounds (cont.) Vascular soundsVascular sounds

• As you listen to abdomen, note presence of any vascular As you listen to abdomen, note presence of any vascular sounds or bruitssounds or bruits

• Using firmer pressure, check over aorta, renal arteries, Using firmer pressure, check over aorta, renal arteries, iliac, and femoral arteries, especially in people with iliac, and femoral arteries, especially in people with hypertensionhypertension

• Usually, no such sound is presentUsually, no such sound is present

Slide 21-54




Percuss general tympany, liver, and splenic Percuss general tympany, liver, and splenic dullnessdullness Percuss to assess relative density of abdominal Percuss to assess relative density of abdominal

contents, to locate organs, and to screen for contents, to locate organs, and to screen for abnormal fluid or massesabnormal fluid or masses

General tympanyGeneral tympany• First, percuss lightly in all four quadrants to determine First, percuss lightly in all four quadrants to determine

prevailing amount of tympany and dullness prevailing amount of tympany and dullness

• Move clockwise; tympany should predominate because Move clockwise; tympany should predominate because air in intestines rises to surface when person is supineair in intestines rises to surface when person is supine

Slide 21-55




Percuss general tympany, liver, and splenic Percuss general tympany, liver, and splenic dullness (cont.)dullness (cont.) Liver spanLiver span

• Percuss to map out boundaries of certain organs Percuss to map out boundaries of certain organs

• Measure height of liver in right midclavicular lineMeasure height of liver in right midclavicular line

• For consistent placement of midclavicular line landmark, For consistent placement of midclavicular line landmark, remember to palpate acromioclavicular and remember to palpate acromioclavicular and sternoclavicular joints and judge line at point midway sternoclavicular joints and judge line at point midway between twobetween two

• Begin in area of lung resonance, and percuss down Begin in area of lung resonance, and percuss down interspaces until sound changes to a dull qualityinterspaces until sound changes to a dull quality

Slide 21-56




Percuss general tympany, liver, and splenic Percuss general tympany, liver, and splenic dullnessdullness (cont.)(cont.) Liver span (cont.)Liver span (cont.)

• Mark spot, usually in fifth intercostal spaceMark spot, usually in fifth intercostal space

• Find abdominal tympany and percuss up in midclavicular Find abdominal tympany and percuss up in midclavicular lineline

• Mark where sound changes from tympany to a dull Mark where sound changes from tympany to a dull sound, normally at right costal marginsound, normally at right costal margin

• Measure distance between two marks; normal liver span Measure distance between two marks; normal liver span in adult ranges from 6 to 12 cmin adult ranges from 6 to 12 cm

• Height of liver span correlates with height of person; Height of liver span correlates with height of person; taller people have longer liverstaller people have longer livers

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• Also males have larger liver span than females of the Also males have larger liver span than females of the same heightsame height

• Overall, mean liver span is 10.5 cm for males and 7 cm Overall, mean liver span is 10.5 cm for males and 7 cm for femalesfor females

• One variation occurs in people with chronic emphysema, One variation occurs in people with chronic emphysema, in which liver displaced downward by hyperinflated lungs in which liver displaced downward by hyperinflated lungs

• Although you hear a dull percussion note well below right Although you hear a dull percussion note well below right costal margin, overall span is still within normal limitscostal margin, overall span is still within normal limits

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• Clinical estimation of liver span important to screen for Clinical estimation of liver span important to screen for hepatomegaly and to monitor changes in liver sizehepatomegaly and to monitor changes in liver size

• However, this measurement is a gross estimate; liver However, this measurement is a gross estimate; liver span may be underestimated because of inaccurate span may be underestimated because of inaccurate detection of upper borderdetection of upper border

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• Scratch Test: one final technique is scratch test, which Scratch Test: one final technique is scratch test, which may help define liver border when abdomen distended or may help define liver border when abdomen distended or abdominal muscles are tenseabdominal muscles are tense

• Place your stethoscope over liverPlace your stethoscope over liver

• With one fingernail, scratch short strokes over abdomen, With one fingernail, scratch short strokes over abdomen, starting in RLQ and moving progressively up toward liver starting in RLQ and moving progressively up toward liver

• When scratching sound in your stethoscope becomes When scratching sound in your stethoscope becomes magnified, you will have crossed border from over a magnified, you will have crossed border from over a hollow organ to a solid onehollow organ to a solid one

Slide 21-60




Percuss general tympany, liver, and splenic Percuss general tympany, liver, and splenic dullness (cont.)dullness (cont.) Splenic dullnessSplenic dullness

• Often spleen obscured by stomach contents, but you Often spleen obscured by stomach contents, but you may locate it by percussing for a dull note from 9th to may locate it by percussing for a dull note from 9th to 11th intercostal space just behind left midaxillary line 11th intercostal space just behind left midaxillary line

• Area of splenic dullness normally is not wider than 7 cm Area of splenic dullness normally is not wider than 7 cm in adult and should not encroach on normal tympany in adult and should not encroach on normal tympany over gastric air bubbleover gastric air bubble

• Percuss in lowest interspace in left anterior axillary linePercuss in lowest interspace in left anterior axillary line

• Tympany should result; ask person to take a deep Tympany should result; ask person to take a deep breath; normally tympany remains through full inspirationbreath; normally tympany remains through full inspiration

Slide 21-61




Percuss general tympany, liver, and splenic Percuss general tympany, liver, and splenic dullness (cont.)dullness (cont.) Costovertebral angle tendernessCostovertebral angle tenderness

• Indirect fist percussion causes tissues to vibrate instead Indirect fist percussion causes tissues to vibrate instead of producing a soundof producing a sound

• To assess kidney, place one hand over 12th rib at To assess kidney, place one hand over 12th rib at costovertebral angle on backcostovertebral angle on back

• Thump that hand with ulnar edge of your other fistThump that hand with ulnar edge of your other fist

• Person normally feels thud but no painPerson normally feels thud but no pain Its usual sequence in complete examination is with thoracic Its usual sequence in complete examination is with thoracic

assessment, when person is sitting up and you are assessment, when person is sitting up and you are standing behindstanding behind

Slide 21-62




Percuss general tympany, liver, and splenic Percuss general tympany, liver, and splenic dullness (cont.)dullness (cont.) Special proceduresSpecial procedures

• At times, you may suspect that a person has ascites At times, you may suspect that a person has ascites (free fluid in the peritoneal cavity) because of distended (free fluid in the peritoneal cavity) because of distended abdomen, bulging flanks, and an umbilicus that is abdomen, bulging flanks, and an umbilicus that is protruding and displaced downwardprotruding and displaced downward

• You can differentiate ascites from gaseous distention by You can differentiate ascites from gaseous distention by performing two percussion testsperforming two percussion tests

Fluid wave testFluid wave test Shifting dullness testShifting dullness test

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Palpate surface and deep areasPalpate surface and deep areas Perform palpationPerform palpation

• Judge size, location, and consistency of certain organs Judge size, location, and consistency of certain organs and screen for an abnormal mass or tendernessand screen for an abnormal mass or tenderness

• Because most people are naturally inclined to protect Because most people are naturally inclined to protect abdomen, you need to use additional measures to abdomen, you need to use additional measures to enhance complete muscle relaxationenhance complete muscle relaxation

Slide 21-64




Palpate surface and deep areasPalpate surface and deep areas (cont.)(cont.) Perform palpation (cont.)Perform palpation (cont.)

• Additional measures to enhance complete muscle Additional measures to enhance complete muscle relaxationrelaxation

Bend person’s kneesBend person’s knees Keep your palpating hand low and parallel to abdomenKeep your palpating hand low and parallel to abdomen Teach person to breathe slowly; in through nose, and out Teach person to breathe slowly; in through nose, and out

through mouththrough mouth Keep your own voice low and soothing; conversation may Keep your own voice low and soothing; conversation may

relax personrelax person Try “emotive imagery,” e.g., you might say, “Now I want Try “emotive imagery,” e.g., you might say, “Now I want

you to imagine you are dozing on beach, with sun warming you to imagine you are dozing on beach, with sun warming your muscles and sound of the waves lulling you to sleep.”your muscles and sound of the waves lulling you to sleep.”

Slide 21-65




Palpate surface and deep areas (cont.)Palpate surface and deep areas (cont.) Perform palpationPerform palpation

• Additional measures to enhance complete muscle Additional measures to enhance complete muscle relaxation (cont.)relaxation (cont.)

With very ticklish person, keep person’s hand under your With very ticklish person, keep person’s hand under your own with your fingers curled over his or her fingersown with your fingers curled over his or her fingers

Move both hands around as you palpate; people are not Move both hands around as you palpate; people are not ticklish to themselvesticklish to themselves

Alternatively, perform palpation just after auscultationAlternatively, perform palpation just after auscultation Keep stethoscope in place and curl your fingers around it, Keep stethoscope in place and curl your fingers around it,

palpating as you pretend to auscultatepalpating as you pretend to auscultate People do not perceive stethoscope as ticklish objectPeople do not perceive stethoscope as ticklish object Slide stethoscope out when person used to being touchedSlide stethoscope out when person used to being touched

Slide 21-66




Palpate surface and deep areasPalpate surface and deep areas (cont.)(cont.) Light and deep palpation (cont.)Light and deep palpation (cont.)

• Begin with light palpationBegin with light palpation

• With first four fingers close together, depress skin about With first four fingers close together, depress skin about 1 cm 1 cm

• Make gentle rotary motion, sliding fingers and skin Make gentle rotary motion, sliding fingers and skin togethertogether

• Then lift fingers (do not drag them) and move clockwise Then lift fingers (do not drag them) and move clockwise to next location around abdomento next location around abdomen

• Objective is not to search for organs but to form an Objective is not to search for organs but to form an overall impression of skin surface and superficial overall impression of skin surface and superficial musculaturemusculature

Slide 21-67





• Save examination of any identified tender areas until lastSave examination of any identified tender areas until last

• This method avoids pain and resulting muscle rigidity This method avoids pain and resulting muscle rigidity that would obscure deep palpation later in examinationthat would obscure deep palpation later in examination

• As you circle abdomen, discriminate between voluntary As you circle abdomen, discriminate between voluntary muscle guarding and involuntary rigiditymuscle guarding and involuntary rigidity

• Voluntary guarding occurs when person is cold, tense, or Voluntary guarding occurs when person is cold, tense, or ticklish; it is bilateral, and you will feel muscles relax ticklish; it is bilateral, and you will feel muscles relax slightly during exhalation; use relaxation measures to try slightly during exhalation; use relaxation measures to try to eliminate this type of guardingto eliminate this type of guarding

• If rigidity persists, it is probably involuntaryIf rigidity persists, it is probably involuntary

Slide 21-68





• Now perform deep palpation using same technique Now perform deep palpation using same technique described earlier, but push down about 5 to 8 cm (2 to 3 described earlier, but push down about 5 to 8 cm (2 to 3 inches) inches)

• Moving clockwise, explore entire abdomenMoving clockwise, explore entire abdomen

• To overcome resistance of a very large or obese To overcome resistance of a very large or obese abdomen, use a bimanual techniqueabdomen, use a bimanual technique

Place your two hands on top of each otherPlace your two hands on top of each other Top hand does pushing; bottom hand relaxed and can Top hand does pushing; bottom hand relaxed and can

concentrate on sense of palpationconcentrate on sense of palpation

Slide 21-69





• With either technique, note location, size, consistency, With either technique, note location, size, consistency, and mobility of any palpable organs and presence of any and mobility of any palpable organs and presence of any abnormal enlargement, tenderness, or massesabnormal enlargement, tenderness, or masses

• Making sense of what you are feeling is more difficult Making sense of what you are feeling is more difficult than it looksthan it looks

• Inexperienced examiners complain that abdomen “all Inexperienced examiners complain that abdomen “all feels same,” as if they are pushing their hand into a soft feels same,” as if they are pushing their hand into a soft sofa cushionsofa cushion

• Helps to memorize anatomy and visualize what is under Helps to memorize anatomy and visualize what is under each quadrant as you palpateeach quadrant as you palpate

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• Also remember that some structures are normally Also remember that some structures are normally palpablepalpable

• Mild tenderness normally present when palpating Mild tenderness normally present when palpating sigmoid colonsigmoid colon

• Any other tenderness should be investigatedAny other tenderness should be investigated

• If you identify a mass, first distinguish it from a normally If you identify a mass, first distinguish it from a normally palpable structure or an enlarged organpalpable structure or an enlarged organ

Slide 21-71





• Then note the following:Then note the following: LocationLocation SizeSize ShapeShape Consistency: soft, firm, hardConsistency: soft, firm, hard Surface: smooth, nodularSurface: smooth, nodular Mobility, including movement with respirationsMobility, including movement with respirations PulsatilityPulsatility TendernessTenderness

Slide 21-72



Normally Palpable StructuresNormally Palpable Structures

Slide 21-73




Palpate surface and deep areas (cont.)Palpate surface and deep areas (cont.) LiverLiver

• Place your left hand under person’s back parallel to 11th Place your left hand under person’s back parallel to 11th and 12th ribs and lift up to support abdominal contentsand 12th ribs and lift up to support abdominal contents

• Place your right hand on RUQ, with fingers parallel to Place your right hand on RUQ, with fingers parallel to midlinemidline

• Push deeply down and under right costal marginPush deeply down and under right costal margin

• Ask person to take a deep breath; it is normal to feel Ask person to take a deep breath; it is normal to feel edge of liver bump your fingertips as diaphragm pushes edge of liver bump your fingertips as diaphragm pushes it down during inhalationit down during inhalation

• It feels like a firm regular ridge; often liver is not palpableIt feels like a firm regular ridge; often liver is not palpable

Slide 21-74




Palpate surface and deep areasPalpate surface and deep areas (cont.)(cont.) Liver (cont.)Liver (cont.)

• Hooking TechniqueHooking Technique An alternative method of palpating liver is to stand up at An alternative method of palpating liver is to stand up at

person’s shoulder and swivel your body to right so that you person’s shoulder and swivel your body to right so that you face person’s feetface person’s feet

Hook your fingers over costal margin from aboveHook your fingers over costal margin from above Ask person to take a deep breathAsk person to take a deep breath Try to feel liver edge bump your fingertipsTry to feel liver edge bump your fingertips

Slide 21-75




Palpate surface and deep areas (cont.)Palpate surface and deep areas (cont.) SpleenSpleen

• Normally spleen is not palpable and must be enlarged Normally spleen is not palpable and must be enlarged three times its normal size to be feltthree times its normal size to be felt

• To search for it, reach your left hand over abdomen and To search for it, reach your left hand over abdomen and behind left side at the 11th and 12th ribs behind left side at the 11th and 12th ribs

• Lift up for support; place your right hand obliquely on Lift up for support; place your right hand obliquely on LUQ with fingers pointing toward left axilla and just LUQ with fingers pointing toward left axilla and just inferior to rib margininferior to rib margin

• Push your hand deeply down and under left costal Push your hand deeply down and under left costal margin and ask person to take deep breathmargin and ask person to take deep breath

• You should feel nothing firmYou should feel nothing firm

Slide 21-76




Palpate surface and deep areasPalpate surface and deep areas (cont.)(cont.) Spleen (cont.)Spleen (cont.)

• When enlarged, spleen slides out and bumps your When enlarged, spleen slides out and bumps your fingertipsfingertips

• It can grow so large that it extends into lower quadrantsIt can grow so large that it extends into lower quadrants

• When this condition is suspected, start low so you will When this condition is suspected, start low so you will not miss itnot miss it

• An alternative position is to roll person onto his or her An alternative position is to roll person onto his or her right side to displace spleen more forward and downward right side to displace spleen more forward and downward

• Then palpate as described earlierThen palpate as described earlier

Slide 21-77




Palpate surface and deep areasPalpate surface and deep areas (cont.)(cont.) KidneysKidneys

• Search for right kidney by placing your hands together in Search for right kidney by placing your hands together in a “duck-bill” position at person’s right flanka “duck-bill” position at person’s right flank

• Press your two hands together firmly (you need deeper Press your two hands together firmly (you need deeper palpation than that used with the liver or spleen) and ask palpation than that used with the liver or spleen) and ask person to take deep breathperson to take deep breath

• In most people, you will feel no changeIn most people, you will feel no change

• Occasionally, you may feel lower pole of right kidney as Occasionally, you may feel lower pole of right kidney as a round, smooth mass slide between your fingersa round, smooth mass slide between your fingers

• Either condition is normalEither condition is normal

Slide 21-78




Palpate surface and deep areasPalpate surface and deep areas (cont.)(cont.) Kidneys (cont.)Kidneys (cont.)

• Left kidney sits 1 cm higher than right kidney and is not Left kidney sits 1 cm higher than right kidney and is not palpable normallypalpable normally

• Search for it by reaching your left hand across abdomen Search for it by reaching your left hand across abdomen and behind left flank for supportand behind left flank for support

• Push your right hand deep into abdomen and ask person Push your right hand deep into abdomen and ask person to breathe deeplyto breathe deeply

• You should feel no change with inhalationYou should feel no change with inhalation

Slide 21-79




Palpate surface and deep areasPalpate surface and deep areas (cont.)(cont.) AortaAorta

• Using your opposing thumb and fingers, palpate aortic Using your opposing thumb and fingers, palpate aortic pulsation in upper abdomen slightly to left of midlinepulsation in upper abdomen slightly to left of midline

• Normally, it is 2.5 to 4 cm wide in adult and pulsates in Normally, it is 2.5 to 4 cm wide in adult and pulsates in an anterior directionan anterior direction

Slide 21-80




Special problems for advanced practiceSpecial problems for advanced practice Rebound tenderness, Blumberg’s signRebound tenderness, Blumberg’s sign Inspiratory arrest, Murphy’s signInspiratory arrest, Murphy’s sign Iliopsoas muscle testIliopsoas muscle test Obturator testObturator test

Slide 21-81



Objective Data:Objective Data:Developmental CompetenceDevelopmental Competence

InfantInfant InspectionInspection

• Contour of abdomen is protuberant because of immature Contour of abdomen is protuberant because of immature abdominal musculatureabdominal musculature

• Skin contains a fine, superficial venous pattern; this may Skin contains a fine, superficial venous pattern; this may be visible in lightly pigmented children up to pubertybe visible in lightly pigmented children up to puberty

• Inspect umbilical cord throughout neonatal periodInspect umbilical cord throughout neonatal period

• At birth, it is white and contains two umbilical arteries At birth, it is white and contains two umbilical arteries and one vein surrounded by mucoid connective tissue, and one vein surrounded by mucoid connective tissue, called Wharton jellycalled Wharton jelly

• Umbilical stump dries within a week, hardens, and falls Umbilical stump dries within a week, hardens, and falls off by 10 to 14 days; skin covers area by 3 to 4 weeksoff by 10 to 14 days; skin covers area by 3 to 4 weeks

Slide 21-82




(cont.)(cont.) InfantInfant

Inspection (cont.)Inspection (cont.)• Abdomen should be symmetric, although two bulges Abdomen should be symmetric, although two bulges

commoncommon

• May note an umbilical hernia; appears at 2 to 3 weeks May note an umbilical hernia; appears at 2 to 3 weeks and especially prominent when infant criesand especially prominent when infant cries

Reaches maximum size at 1 month (up to 2.5 cm or 1 inch) Reaches maximum size at 1 month (up to 2.5 cm or 1 inch) and usually disappears by 1 yearand usually disappears by 1 year

• Another common variation is diastasis recti, a separation Another common variation is diastasis recti, a separation of rectus muscles with a visible bulge along midlineof rectus muscles with a visible bulge along midline

• Condition more common with black infants, and it usually Condition more common with black infants, and it usually disappears by early childhooddisappears by early childhood

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Inspection (cont.)Inspection (cont.)• Abdomen shows respiratory movementAbdomen shows respiratory movement

• Only other abdominal movement you should note is Only other abdominal movement you should note is occasional peristalsis, which may be visible because of occasional peristalsis, which may be visible because of thin musculaturethin musculature

AuscultationAuscultation• Auscultation yields only bowel sounds, metallic tinkling of Auscultation yields only bowel sounds, metallic tinkling of

peristalsisperistalsis

• No vascular sounds should be heardNo vascular sounds should be heard

Slide 21-84




(cont.)(cont.) Infant (cont.)Infant (cont.)

PercussionPercussion• Percussion finds tympany over stomach (the infant Percussion finds tympany over stomach (the infant

swallows some air with feeding) and dullness over liverswallows some air with feeding) and dullness over liver

• Percussing the spleen is not donePercussing the spleen is not done

• Abdomen sounds tympanitic, although it is normal to Abdomen sounds tympanitic, although it is normal to percuss dullness over bladder; dullness may extend up percuss dullness over bladder; dullness may extend up to umbilicusto umbilicus

PalpationPalpation• Aid palpation by flexing baby’s knees with one hand Aid palpation by flexing baby’s knees with one hand

while palpating with otherwhile palpating with other

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Palpation (cont.)Palpation (cont.)• Alternatively, you may hold upper back and flex neck Alternatively, you may hold upper back and flex neck

slightly with one hand; offer pacifier to a crying infantslightly with one hand; offer pacifier to a crying infant

• Liver fills RUQ; normal to feel liver edge at right costal Liver fills RUQ; normal to feel liver edge at right costal margin or 1 to 2 cm belowmargin or 1 to 2 cm below

• Normally, you may palpate spleen tip and both kidneys Normally, you may palpate spleen tip and both kidneys and bladder and bladder

• Also easily palpated are cecum in RLQ, and sigmoid Also easily palpated are cecum in RLQ, and sigmoid colon, which feels like a sausage in left inguinal areacolon, which feels like a sausage in left inguinal area

• Make note of newborn’s first stool, a sticky, greenish-Make note of newborn’s first stool, a sticky, greenish-black meconium stool within 24 hours of birthblack meconium stool within 24 hours of birth

Slide 21-86




(cont.)(cont.) ChildChild

Under age 4 years abdomen looks protuberant Under age 4 years abdomen looks protuberant when child is both supine and standingwhen child is both supine and standing

After age 4 years, potbelly remains when standing After age 4 years, potbelly remains when standing because of lumbar lordosis, but abdomen looks because of lumbar lordosis, but abdomen looks flat when supineflat when supine• Normal movement on abdomen includes respirations, Normal movement on abdomen includes respirations,

which remain abdominal until 7 yearswhich remain abdominal until 7 years

• To palpate abdomen, position young child on parent’s To palpate abdomen, position young child on parent’s lap as you sit knee-to-knee with parentlap as you sit knee-to-knee with parent

• Flex knees up, and elevate head slightlyFlex knees up, and elevate head slightly

Slide 21-87




(cont.)(cont.) Child (cont.)Child (cont.)

Child can “pant like a dog” to further relax Child can “pant like a dog” to further relax abdominal musclesabdominal muscles• Hold your entire palm flat on abdominal surface for a Hold your entire palm flat on abdominal surface for a

moment before starting palpationmoment before starting palpation

• This accustoms child to being touchedThis accustoms child to being touched

• If the child is very ticklish, hold his or her hand under If the child is very ticklish, hold his or her hand under your own as you palpate; or apply stethoscope and your own as you palpate; or apply stethoscope and palpate around itpalpate around it

Liver Liver • Remains easily palpable 1 to 2 cm below right costal Remains easily palpable 1 to 2 cm below right costal

margin; edge is soft and sharp and moves easilymargin; edge is soft and sharp and moves easily

Slide 21-88





• Easily palpable, on the left, the spleen also is easily Easily palpable, on the left, the spleen also is easily palpable with a soft, sharp, movable edgepalpable with a soft, sharp, movable edge

• Usually you can feel 1 to 2 cm of right kidney and tip of Usually you can feel 1 to 2 cm of right kidney and tip of left kidneyleft kidney

• Percussion of liver span measures about 3.5 cm at age 2 Percussion of liver span measures about 3.5 cm at age 2 years, 5 cm at age 6 years, and 6 to 7 cm during years, 5 cm at age 6 years, and 6 to 7 cm during adolescenceadolescence

• In assessing abdominal tenderness, remember that In assessing abdominal tenderness, remember that young child often answers this question affirmatively no young child often answers this question affirmatively no matter how abdomen actually feelsmatter how abdomen actually feels

Slide 21-89





• Use objective signs to aid assessment, such as a cry Use objective signs to aid assessment, such as a cry changing in pitch as you palpate, facial grimacing, changing in pitch as you palpate, facial grimacing, moving away from you, and guardingmoving away from you, and guarding

• School-age child has a slim abdominal shape as he or School-age child has a slim abdominal shape as he or she loses potbellyshe loses potbelly

• This slimming trend continues into adolescenceThis slimming trend continues into adolescence

• Adolescent easily embarrassed with exposure of Adolescent easily embarrassed with exposure of abdomen, and adequate draping is necessaryabdomen, and adequate draping is necessary

• Physical findings are same as those listed for adultPhysical findings are same as those listed for adult

Slide 21-90




(cont.)(cont.) Aging adultAging adult

• On inspection, you may note increased deposits of On inspection, you may note increased deposits of subcutaneous fat on abdomen and hips because it is subcutaneous fat on abdomen and hips because it is redistributed away from extremitiesredistributed away from extremities

• Abdominal musculature is thinner and has less tone than Abdominal musculature is thinner and has less tone than that of younger adult, so in absence of obesity you may that of younger adult, so in absence of obesity you may note peristalsisnote peristalsis

• Because of thinner, softer abdominal wall, organs may Because of thinner, softer abdominal wall, organs may be easier to palpate, in the absence of obesitybe easier to palpate, in the absence of obesity

• Liver is easier to palpate; normally, you will feel liver Liver is easier to palpate; normally, you will feel liver edge at or just below costal marginedge at or just below costal margin

Slide 21-91





• With distended lungs and depressed diaphragm, liver With distended lungs and depressed diaphragm, liver can be palpated lower, descending 1 to 2 cm below can be palpated lower, descending 1 to 2 cm below costal margin with inhalationcostal margin with inhalation

• Kidneys are easier to palpateKidneys are easier to palpate

Slide 21-92



Sample chartingSample charting

Slide 21-93



Sample chartingSample charting (cont.)(cont.)

Slide 23-94



Abnormal Findings:Abnormal Findings:Abdominal DistentionAbdominal Distention

ObesityObesity Air or gasAir or gas AscitesAscites Ovarian cystOvarian cyst PregnancyPregnancy FecesFeces TumorTumor

Slide 21-95



Abnormal Findings:Abnormal Findings:Abnormalities on InspectionAbnormalities on Inspection

Umbilical herniaUmbilical hernia Epigastric herniaEpigastric hernia Incisional herniaIncisional hernia Diastasis rectiDiastasis recti

Slide 21-96



Abnormal Findings:Abnormal Findings:Abnormal Bowel SoundsAbnormal Bowel Sounds

Succussion splashSuccussion splash Hypoactive bowel soundsHypoactive bowel sounds Hyperactive bowel soundsHyperactive bowel sounds

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Abnormal Findings:Abnormal Findings:On Palpation of Enlarged OrgansOn Palpation of Enlarged Organs

Enlarged liverEnlarged liver Enlarged nodular liverEnlarged nodular liver Enlarged gallbladderEnlarged gallbladder Enlarged spleenEnlarged spleen Enlarged kidneyEnlarged kidney Aortic aneurysmAortic aneurysm

Slide 21-98

Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of...

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Transcript of Elsevier items and derived items © 2012, 2008, 2004, 2000, 1996, 1992 by Saunders, an imprint of...