abdomen assessment d. tanner, rn, msn nur 211 fall semester
TRANSCRIPT
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Abdomen AssessmentAbdomen Assessment
D. Tanner, RN, MSND. Tanner, RN, MSN
NUR 211NUR 211
Fall Semester Fall Semester
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Anatomy of the AbdomenAnatomy of the Abdomen
4 Quadrants RUQ, RLQ, LUQ, 4 Quadrants RUQ, RLQ, LUQ, LLQLLQ
MidlineMidline
9 Regions- epigastric, 9 Regions- epigastric, umbilical, suprapubicumbilical, suprapubic
The word "abdomen" has a The word "abdomen" has a curious story behind it. It curious story behind it. It comes from the Latin comes from the Latin "abdodere", to hide. The idea "abdodere", to hide. The idea was that whatever was eaten was that whatever was eaten was hidden in the abdomen.was hidden in the abdomen.
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4 Quadrants4 Quadrants
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9 Regions9 Regions
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Location! Location! Location! Location! Location!Location!
RUQRUQ
liverliver
gallbladdergallbladder
duodenum (small duodenum (small intestine)intestine)
pancreas headpancreas head
right kidney and right kidney and adrenaladrenal
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Location! Location! Location! Location! Location!Location!
RLQRLQ
cecumcecum
appendixappendix
right ovary and right ovary and tubetube
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Location! Location! Location! Location! Location!Location!
LLQLLQ
sigmoid colonsigmoid colonleft ovary and tubeleft ovary and tube
LUQLUQ
stomachstomachspleenspleenpancreaspancreasleft kidney and adrenalleft kidney and adrenal
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GI Variations Due to AgeGI Variations Due to Age
Aging- should not affect Aging- should not affect GI function unless GI function unless associated with a associated with a disease processdisease process
Decreased: salivation, Decreased: salivation, sense of taste, gastric sense of taste, gastric acid secretion, acid secretion, esophageal emptying, esophageal emptying, liver size, bacterial floraliver size, bacterial flora
Increased: constipation!Increased: constipation!
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GI Variations with GI Variations with pregnancypregnancy
Decrease in gastric Decrease in gastric motilitymotility
High incidence of N, V (r/t High incidence of N, V (r/t pregnancy hormones) pregnancy hormones) and “heartburn” or acid and “heartburn” or acid refluxreflux
Bowel sounds diminished Bowel sounds diminished r/t enlarged uterus r/t enlarged uterus displacing intestinesdisplacing intestines
Linea nigra- increased Linea nigra- increased pigmentation of abd pigmentation of abd midlinemidline
Striae GravidarumStriae Gravidarum
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Nursing History - AbdomenNursing History - Abdomen
Subjective DataSubjective Data: : Ask about:Ask about:AppetiteAppetiteWt gain or lossWt gain or lossDysphagiaDysphagiaIntolerance to certain Intolerance to certain foodsfoodsAny Abdominal Pain of Any Abdominal Pain of Nausea and VomitingNausea and VomitingBowel movementsBowel movementsAny past abdominal Any past abdominal problemsproblems
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Nursing HistoryNursing History
Infants and Children – Infants and Children – Ask: bottle or breast fed, any table Ask: bottle or breast fed, any table
foods, how often & how well & how foods, how often & how well & how much the baby eat, any problems with much the baby eat, any problems with constipation, c/o of any abdominal painconstipation, c/o of any abdominal pain
Teenagers-Teenagers- Ask: nutritional assessment, activity & Ask: nutritional assessment, activity &
exercise patterns, recent wt. loss or gain exercise patterns, recent wt. loss or gain
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Nursing HistoryNursing History
Older AdultsOlder Adults Ask: how do you get your groceries?Ask: how do you get your groceries?
prepare your meals? prepare your meals? do you have any trouble swallowing?do you have any trouble swallowing?
how often do your bowels move?how often do your bowels move?how often do you take anything for how often do you take anything for constipation? Rx / OTC/ herbsconstipation? Rx / OTC/ herbswhat meds do you take?what meds do you take?
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Nursing AssessmentNursing Assessment
Objective DataObjective Data::
General ObservationGeneral Observation
InspectInspect
AuscultateAuscultate
PercussPercuss
Palpate (always last)Palpate (always last)
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Focused Health HistoryFocused Health History
NutritionNutrition AllergiesAllergies MedicationsMedications Cigarette/tobaccoCigarette/tobacco ETOH intakeETOH intake Recreational drug useRecreational drug use Stool characteristicsStool characteristics Urine characteristicsUrine characteristics Exposure to infectious Exposure to infectious
dz.dz. Recent stressful life Recent stressful life
eventsevents Possibility of PregnancyPossibility of Pregnancy
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Techniques for ExamTechniques for Exam
Provide privacyProvide privacy Good lighting/appropriate temp in rmGood lighting/appropriate temp in rm Expose the abdomenExpose the abdomen Empty bladderEmpty bladder Position pt supine, arms by side & head on Position pt supine, arms by side & head on
pillow with knees slightly bent or on a pillowpillow with knees slightly bent or on a pillow Warm stethoscope & handsWarm stethoscope & hands Painful areas lastPainful areas last Distraction techniquesDistraction techniques
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InspectionInspection
Overall observationOverall observation
Abd contour- flat, Abd contour- flat, scaphoid, round, scaphoid, round, protuberantprotuberant
Abd symmetry and skin Abd symmetry and skin color - note any masses, color - note any masses, striae, scars, veins, striae, scars, veins, pigmentationpigmentation
PulsationsPulsations
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AuscultationAuscultation
Always done before Always done before percussion & percussion & palpationpalpation
Use diaphragm of Use diaphragm of stethoscopestethoscope
Listen lightlyListen lightly
Start with RLQStart with RLQ
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AuscultationAuscultation
What makes a bowel sound?What makes a bowel sound? Note character & frequency of bowel Note character & frequency of bowel
sounds (5-30 times/minute)sounds (5-30 times/minute) Sounds like…..Sounds like….. Listen for 5 minutes before documenting Listen for 5 minutes before documenting
absent bowel soundsabsent bowel sounds Listen for bruits- aortic, renal, iliac, femoralListen for bruits- aortic, renal, iliac, femoral Hyper- gastroenteritis, obstruction, hungryHyper- gastroenteritis, obstruction, hungry Hypo- pregnancy, peritonitisHypo- pregnancy, peritonitis
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PercussionPercussion
Gently tapping on the skin to create a Gently tapping on the skin to create a vibrationvibration
Detect fluid, gaseous distention and Detect fluid, gaseous distention and massesmasses
Tympany- gas (dominant sound because Tympany- gas (dominant sound because of air in sm intestine)of air in sm intestine)
Dullness- solid masses, distended bladderDullness- solid masses, distended bladder Percuss liver, spleen ,kidneysPercuss liver, spleen ,kidneys
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Palpation of AbdomenPalpation of Abdomen
Light palpation- depress about 1 cm. Assess Light palpation- depress about 1 cm. Assess skin pulsations. Always done first- clockwiseskin pulsations. Always done first- clockwise
Deep palpation- depress skin about 5-8 cm.Deep palpation- depress skin about 5-8 cm.
Always assess tender areas last.Always assess tender areas last.
Watch pt’s expression during palpationWatch pt’s expression during palpation
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Inspection Abnormal Inspection Abnormal FindingsFindings
Visible or distended veins- ascitesVisible or distended veins- ascites
Visible peristalsis- obstructionVisible peristalsis- obstruction
Spider nevi (cutaneous angiomas)- cirrhosisSpider nevi (cutaneous angiomas)- cirrhosis
Asymmetry/ Distention- mass or intestinal Asymmetry/ Distention- mass or intestinal obsructionobsruction
Color changes- jaundice, bluish/cyanoticColor changes- jaundice, bluish/cyanotic
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Abnormal AuscultationAbnormal Auscultation
Absence/Hyperactive bowel sounds- Absence/Hyperactive bowel sounds- “borborygmi”“borborygmi”
Bruits- “swoosh”Bruits- “swoosh”
Peritoneal Friction Rub- rough, grating Peritoneal Friction Rub- rough, grating heard over liver & spleen- inflammation of heard over liver & spleen- inflammation of peritoneal surface from tumor, infection, peritoneal surface from tumor, infection, etc.etc.
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Percussion Abnormal Percussion Abnormal FindingsFindings
Enlarged organs, palpable masses, Enlarged organs, palpable masses, distention, ascitesdistention, ascites
Marked tendernessMarked tenderness
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Palpation Abnormal FindingsPalpation Abnormal Findings
Tenderness- rebound- done away from Tenderness- rebound- done away from painful area- done at end of exampainful area- done at end of exam
Masses- document location, size, shape, Masses- document location, size, shape, mobile, pulsating, smooth, nodular, firmmobile, pulsating, smooth, nodular, firm
Firmness or muscle guarding/rigidity- Firmness or muscle guarding/rigidity- intraabdominal bleeding- DO NOT intraabdominal bleeding- DO NOT CONTINUE TO PALPATE!!!!!!CONTINUE TO PALPATE!!!!!!
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Special ProceduresSpecial Procedures
Fluid Wave- need 3 hands- feel for impulse of the Fluid Wave- need 3 hands- feel for impulse of the wave of fluid across the abdomen= asciteswave of fluid across the abdomen= ascites
Rebound Tenderness- Blumberg’s SignRebound Tenderness- Blumberg’s Sign
Iliopsoas Muscle Test- thigh muscle lift R leg and Iliopsoas Muscle Test- thigh muscle lift R leg and push down on R thigh= appendicitispush down on R thigh= appendicitis
Obturator Test- lift R leg and rotate at 90 Obturator Test- lift R leg and rotate at 90 degrees= muscle is irritated by appendicitisdegrees= muscle is irritated by appendicitis
Murphy’s Sign- “inspiratory arrest” palpate the Murphy’s Sign- “inspiratory arrest” palpate the liver should be painless= cholecystitisliver should be painless= cholecystitis
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Special ProceduresSpecial Procedures
McBurney’s Point- RLQ midclavicular= McBurney’s Point- RLQ midclavicular= appendicitisappendicitis
Referred pain- location of pain is not Referred pain- location of pain is not necessarily where the involved organ is! necessarily where the involved organ is! May be felt where the organ was located in May be felt where the organ was located in fetal development ex: spleen= L shoulder fetal development ex: spleen= L shoulder pain/ kidney= groin pain pain/ kidney= groin pain
Hooking technique- palpate the liver- Hooking technique- palpate the liver- feeling for the liver edgefeeling for the liver edge
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Special ProceduresSpecial Procedures
Cullen’s Sign- bluish discoloration Cullen’s Sign- bluish discoloration around the umbilicus EMERGENCY!!!around the umbilicus EMERGENCY!!!
Kehr’s Sign- abd pain radiating to R Kehr’s Sign- abd pain radiating to R shoulder= spleen or pancreatitisshoulder= spleen or pancreatitis
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Sample DocumentationSample Documentation
Normal Exam-Normal Exam-
Abdomen soft, rounded and symmetric without Abdomen soft, rounded and symmetric without distention; no lesions or scars, or visible distention; no lesions or scars, or visible peristalsis. Aorta midline without bruit or visible peristalsis. Aorta midline without bruit or visible pulsation; umbilicus inverted and midline pulsation; umbilicus inverted and midline without herniation; bowel sounds present in all without herniation; bowel sounds present in all 4 quadrants. Liver, kidney and spleen non-4 quadrants. Liver, kidney and spleen non-palpable; no tenderness on palpation. Reports palpable; no tenderness on palpation. Reports good appetite; no constipation, nausea or good appetite; no constipation, nausea or diarrhea. Voiding well and denies laxative use.diarrhea. Voiding well and denies laxative use.