Download - Assessment of the Abdomen

Assessment of the Abdomen

◦Xiphoid process◦Umbilicus◦Costal margins◦Symphysis pubis◦Iliac crest◦Anterior superior iliac spine

Anatomical landmarks

Right Upper Quadrant

◦Liver◦Portions of ascending and transverse colon◦Pylorus valve of stomach◦Hepatic flexure of colon◦Duodenum◦Right kidney and adrenal gland

Right Lower Quadrant

◦Appendix and cecum◦Right ureter ◦Ascending colon◦Right spermatic cord◦Bladder if distended◦Uterus if enlarged◦Ovary

Four Quadrants of Abdomen

Left Upper Quadrant◦Tip of medial lobe of liver ◦Portions of transverse and descending colon ◦Spleen◦Splenic flexure of colon◦Stomach ◦Left kidney and adrenal gland◦Pancreas

Left Lower Quadrant◦Sigmoid colon◦Left ureter ◦Descending colon◦Left spermatic cord◦Bladder if distended◦Uterus if enlarged◦Ovary

Four Quadrants of Abdomen

Chief complaint / present illness◦Abdominal pain◦Constipation◦Indigestion◦Diarrhea◦Nausea◦Vomiting

Collecting SUBJECTIVE DATA

Chief complaint / present illness◦Fecal incontinence ◦Jaundice◦Dysuria ◦Urinary frequency◦Urinary incontinence◦Hematuria, blood in stool◦Weight loss, weight gain


Symptom characteristics◦Onset and duration ◦Prior evaluation or treatment◦Getting better or worse ◦Home or prescribed treatment◦Character or quality ◦Others in family with similar symptoms◦Associated symptoms ◦Alterations in activities of daily living◦Location, radiation◦Factors that relieve or exacerbate

symptoms


Past Medical History (have you had, have you ever had)

Perinatal history◦Pregnancies, abortions, miscarriages

◦Birth defects◦Infant feeding problems◦Prematurity◦Short bowel syndrome

Nursing history to determine

Illnesses / infectious disease Acute GI infections Irritable bowel Hepatitis GERD PID, STI’s Constipation HIV Food allergies / intolerance UTI’s Cystic fibrosis Diverticulitis Colitis Ulcers Gallbladder illness


Immunizations Hepatitis B Cholera Hepatitis A Typhoid Rota virusOther Laboratory test Stool cultures Organ biopsy Abdominal x-ray, sonograms, ultrasounds Sigmoid or colonoscopy Urinalysis Ova and parasites H. pylori tests


Operations / hospitalizations / ER visits Abdominal surgery Recurrent abdominal pain Appendicitis Organ inflammation (liver, pancreas, gallbladder) Trauma to abdomen Acute gastroenteritis (AGE) Births Blood transfusionsAccidents (unintentional injury) Car Falls Bike Skateboard


Medication use (What prescriptions) Antibiotics Folk remedies Laxatives Birth control Suppositories, enemas Iron and vitamins Antacids Chronic steroid or ASA use Ulcer medications Folk remedies Chronic steroid or ASA use Birth control Iron and vitamins


Family History (is there a hx of any of the ff)

Infectious conditions (hepatitis, AGE) Constipation, irritable bowel Ulcers, diverticulitis, inflammatory bowel Gallbladder disease Symptoms similar to CC Colon cancer, ovarian cancer Ova and parasites


Personal and Social History (what types, do you, how much)

Nutrition Last menstrual period Sexual practices and protection Substance use, including caffeine, alcohol,

tobacco Recent stress Weight gain or loss Anorexia, bulimia, dieting Travel outside of country


Preparing the Client: Have child empty bladder Have child lie supine with hips and knees flexed Drape for privacy Tell child what you will do before you do it Have warm room and warm hands Have good light source Examine identified painful areas last Equipment : Small pillow or rolled blanket Tape measure Stethoscope Marking pin

Collecting OBJECTIVE DATA

InspectionSkin Scars Lesions Striae – old silver striae or stretch marks Rashes Dilated veins, vein pattern (hepatic cirrhosis or inferior

vena cava obstruction)Umbilicus Location Contour , Signs of inflammation or bulging, hernia Contour Symmetrical / asymmetrical Scaphoid (concave or hollowed) Flat Protuberant Rounded


Causes of Abdominal Distention Obesity Neoplasms Pregnancy Feces Tympanitis Ascites (Six “F’s”: Fat, Fluid, Flatus, Fetus, Fecus,

Fatal growths)Location of Distention Xiphoid - Diastasis recti Umbilicus - Pregnancy, distended bladder Pubis - Umbilical hernia Midline - Diaphragmatic hernia


Normal Variations of Contour with Age Infant-toddler

◦Protuberant Preschool age child

◦Rounded, lumbar lordosis School age child

◦Scaphoid Adolescent / adult

◦Varied


Inspection◦Peristalsis May be seen in thin individuals or with

obstructive conditions (intestinal obstruction)◦Pulsation Pulsations of descending aorta may be seen in

thin individuals in the epigastrium◦Respirations Abdominal breathing normal until school age

Intercostal breathing occurs with Respiratory distress Abdominal inflammation

Pneumonia or pleural effusion may cause Abdominal pain Altered respirations


Auscultation◦To assess Bowel sounds – (normal sounds

consist of clicks & gurgles)◦Vascular sounds (bruits sounds)◦Organ size, location

Warm stethoscope before use◦Increased bowel sounds

Diarrhea Diverticulitis Colic Intussusception Malrotation

◦Decreased bowel sounds


Total obstructionPeritonitisParalytic ileus Severe ascites Absence of bowel sounds established after 5 minutes of listening◦Scratch test for liver size Intensity of sound increases as you approach liver edge


Techniques for Relaxation of Children for Percussion and Palpation

Pacifier to encourage relaxation with sucking

Flex knees and hips Use of puppets or toys Distraction, support of caregiver Involve them in procedure Reassure procedure will not hurt


Percussion◦Percussion is excellent for assessing organ

size, presence of masses, fluid or gas.◦Tympany stomach, bowel◦Resonance bowel◦Dullness liver◦Flat thigh

Tympany ◦High pitch note elicited over air filled

structures, such as viscera and stomach.


Dull ◦Short high-pitched sound with little

resonance. Found in solid or fluid filled organs adjacent to air containing organs, i.e., liver, spleen, distended bladder.

Flat ◦Very short, high-pitched sound produced

over tissue which contains no air, i.e., muscle, large solid mass.


Percuss ◦4 quadrants for gas or masses (Solid or

fluid filled)◦Liver span◦Spleen size◦Costovertebral angle (CVA) tenderness

Liver percussion◦At right mid-clavicular line, start below

umbilicus and percuss upward until dullness of sound heard

◦Liver usually @ right costal margin +/- 2 cm◦Size and shape of liver vary


Spleen Percussion◦Splenic dullness may be heard near left 10th

rib posterior to the mid-axillary line Usually not found unless enlarged Obscured by air in the colon

◦Percuss at 10th intercostal space to determine dullness with deep breath

◦For spleenomegaly Percuss the lowest interspace in the left

anterior axillary line – usually tympanitic Percussion for tenderness of liver or kidneys

◦Place palm of one hand over organ. Strike hand with ulnar surface of other hand. If organ is inflamed, this will result in pain.


Palpation Light palpation

◦ Assessment of skin turgor ◦ Muscle tone/resistance◦ Superficial lesions or masses◦ Areas of tenderness

Deep palpation Assess for masses or enlarged organs Mass descriptors

◦ Location ◦ Mobility ◦ Size◦ Pulsation◦ Shape◦ Tenderness◦ Consistency


◦ Liver Normally palpable near right costal margin,

mid-clavicular line. Palpate with right hand starting below

umbilicus and moving upward until liver palpable.

Remember the liver is a superficial organ.◦ Spleen

Difficult to palpate unless enlarged Deep palpation under L costal margin at the

anterior axillary line Will descend with deep inspiration Can roll person to R side to move spleen

towards midline

Collecting objective data

Kidneys Difficult to palpate unless enlarged With hands perpendicular to midline between rib

cage and iliac crest, press hands gently but firmly together.

Have person take deep breath. May feel kidney slide between hands. Right

kidney normally lower than left kidney.Stool

Firm, movable, mildly tender, elongated mass often palpable in sigmoid colonBladder

If distended, bladder is palpable midline above symphysis pubis

Smooth round mass, not moveable


Special maneuvers Rebound tenderness Psoas maneuver Obturator sign Murphy’s signRebound Tenderness at McBurney Point Sharp pain when pressure released in RLQ suggest appendicitis Obturator Muscle Test Flex R leg at hip & knee. Rotate leg laterally & medially. Pain in hypogastric region may indicate ruptured appendix Iliopsoas Muscle Test Ask to raise the R leg flexing at the hip while pressing down on lower thigh. Lower quadrant pain may indicate

appendicitis.Murphy’s Sign Client complains of sharp pain when trying to take a deep breath

while examiner performs deep palpation in URQ. Inflamed gallbladder descends during inspiration resulting in pain


Hernias Protrusions of the peritoneum or intestine

through a weakened spot in musculature of abdominal wall. Umbilical hernias rarely need intervention. Inguinal and femoral hernias are usually surgically corrected.◦ Inspection - Assess for bulges with crying or

bearing down.◦ Auscultation - Assess for hums or bruits - should

not be present. May hear bowel sounds.◦ Percussion - Can not percuss hernia.◦ Palpation- Mass soft, nontender and retractable.

Measure opening in musculature with finger tips.

Common Abnormal Abdominal Findings

Pyloric Stenosis Hypertrophy of the pyloric valve prevents feed from

leaving the stomach. Infant initially feeds well but then develops persistent vomiting.

Inspection Peristalic wave over stomach area -

Projectile vomitingAuscultation Hyperactive sounds over stomach area Hyperactive sounds over intestinesPercussion Resonant stomach sounds. Contents expelled.Palpation An enlarged, firm, “olive shape” mass may be

palpable in RUQ. Needs to be referred to MD for ultrasound testing and then surgery.


Appendicitis Appendicitis is the most common cause of acute surgical abdomen in

childhood. ◦ Rare in early childhood, becoming more frequent after age 10. ◦ History includes dull aching, steady peri-umbilical pain that localizes to

RLQ after 4-6 hours. ◦ Nausea and vomiting frequently occur but there is no change in bowel

habits. Low grade fever may be present.Inspection

◦ Note guarding or pain with walking or coughing. Abdominal distention may be present. Prefer supine position with knees flexed.

Auscultation◦ Bowel sounds may be decreased or hyperactive. Need to auscultate RLL

of lungs carefully to rule out lobar pneumonia with referred pain.Percussion

◦ Increased tenderness may make percussion too uncomfortable to perform.Palpation

◦ Tenderness over area of inflamed appendix, usually RLQ (McBurney point). ◦ Rebound tenderness localized to same area.

Unable to palpate inflamed appendix. Rectal exam usually finds right-sided tenderness.


Abdominal painInspection

◦ Limitation of movement or alterations in breathing pattern (shallow or chest breathing) are important assessment criteria. Watch client climb on or off the exam table

◦ Periumbilical pain less likely to be serious than other locations◦ Evaluate for weight loss or gain

Auscultation◦ Bowel sounds may be increased or decreased◦ Friction rub may be heard with pleural inflammation or peritoneal

inflammation

Percussion◦ Percussion over areas of inflammation may result in pain◦ Watch facial expressions as you attempt to distract individual. Those

who watch you have more pain.

Palpation◦ Palpation may identify localized or generalized pain.◦ Watch facial expressions as you attempt to distract during palpation.◦ Firm but gentle palpation is best.


PregnancyInspection

◦ Enlargement of lower abdomen, midline◦ Enlargement of breast◦ Linea nigra, increase facial pigmentation, striae

Auscultation◦ Fetal heart sounds

Percussion◦ Dull mass in lower abdomen◦ Displaced tympany of bowel and stomach

Palpation◦ Fetal outline◦ Fundus of uterus
