Abdomen

Nursing 330Governors State UniversityShirley Comer

History – Review of Systems

GI– Indigestion/anorexia– N&V, hematemesis– Pain– Dysphasia– Change in bowel

function– Constipation or

Diarrhea– Jaundice

Renal /GU– Supra-pubic pain– Dysuria/urgency/freq– Hesitancy, decreased

stream (males)– Polyuria or nocturia– Urinary incontinence– Hematuria– Kidney/flank pain– Ureteral colic

Inspection

Contour– Stand at pt right side and observe at pt height– Inspect from ribs to pubic bone– Concave, flat, rounded, distended

Symmetry– Shine a light across – Note any masses, bulges or asymmetry– Hernia- Protrusion of bowel loop through abdominal wall

Umbilicus– Normally midline /s discoloration, inflammation or hernia– Inverted or everted– Everted /c pregnancy, ascites, distension, congenital.

Inspection Cont

Skin– Smooth with even color – Redness(inflammation)Jaundice(liver dysfunction)– Skin taunt and shinny /c ascites– Spider nevi (cutaneous angiomas) /c liver disease– Rash with allergic reaction

Inspection cont

Pulsation or movement– In thin pt or children may see aortic pulsations in

epigastric area– May see respiratory movement esp in males– Visible peristalsis may indicate intestional

obstruction

Hair distribution– Uneven may mean vascular problems

Inspection Cont

Demeanor– Should be comfortable and relaxed– Should be lying flat– Restlessness may indicate pain (gastrointeritis or

obstruction– Stillness and resisting movement indicates pain

(Peritonitis)– Knees flexed, facial grimacing, and shallow

respirations also indicate pain

Auscultation

Exception to assessment rule as palpation can stimulate bowel sounds not really there.

If pt has Nasogastric tube to suction, turn the suction off for assessment

Use diaphragm of stethoscope Auscultate ileocecal valve in right lower quad

– Bowel sounds almost always present here

Quadrants of Abdomen

Underlying Abdominal organs

Bowel sounds

Caused by peristalsis Note character and frequency Normally high pitched gurgling sounds (5 to 30 per

min) Don’t count but determine character Hyperactive- occur with early bowel obstruction,

diarrhea, laxative use, subsiding paralytic ileus Hypoactive- or absent- follows anesthesia, bowel

obstruction

Vascular sounds

Normally can not hear vascular sounds Note any bruits Listen over

– Aorta– Renal arteries– Iliac arteries– Femoral arteries

Percussion

Percuss entire abdomen– Should hear tympany– Dullness over distended bladder, fluid or mass

Percuss Liver Span– Measure height in right MCL (usually at 5th ICS)– Measure bottom of liver by percussing up from

abdomen– Span = 6 to 12 cm– Hepatomegaly = enlarged liver

Percussion Cont

Percuss Spleen Percuss along 9th to 11 ICS at left mid axillary

line Span not greater then 7 cm Dullness forward of the midaxillary line

indicates enlarged spleen (mononucleosis, trauma, infection)

Palpation

Light Palpation– One hand, 1cm deep, rotary motion– Move clockwise over abdomen– Note muscle guarding, rigidity, masses, tenderness

Deep Palpation– 5 to 8 cm, clockwise, use 2 hands if needed– Don’t do deep palpation if elicit pain on light – Sigmoid colon may be normally tender

Palpating Masses

If Mass if felt, note– Location– Size– Shape– Consistency (soft, hard, firm)– Smooth or nodular– Mobile or fixed– Pulsation– tenderness

Palpation continued

These structures may be normally palpable in the abdomen

– Right kidney– Liver boarder– Xiphoid process– Aorta– Rectus muscles– Cecum– Uterus– Full bladder– Sacrum– Sigmoid colon

Palpate Liver

2 techniques – 1. Place one hand under waist and lift up. Put other

on top of abdomen under ribs on right– 2. Hook both hand around ribs while standing at pt

shoulder– /c both, have pt take deep breath and feel for liver

boarder sliding over fingers– May not be palpable– Is enlarged if felt more than 1 or 2 cm below rib

boarder

Palpate Spleen

Normally not palpable– On left side place hands as in technique 1 to

palpate liver– On deep inspiration may feel margin against your

finders – If felt is probably enlarged– Don’t continue to palpate-is friable and can rupture

Palpate Kidney

Palpate right kidney-left too high Place hands in Duckbill position at right flank Press finger tips together On deep inspiration may feel kidney lower

surface move against fingers If easily felt = enlarged kidney or mass Easier to feel in children or very thin adults

Kidney location pix

Rebound tenderness

Use If tender elicited on deep palpation Position hand away from tender area Place hand perpendicular to abdomen and

push down slowly Release hand quickly and note any tenderness Indicates peritonitis Perform at end of exam r/t possible severe

pain

Fluid Wave for Ascites

Ascites can occur with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis and cancer

Place pt had in middle of abdomen and your hands on either side.

Firmly tap right right side of abdomen. If fluid present will feel wave on left side

Special Techniques

Murphy's sign - Tenderness in the R upper quadrant (the costal margin, mid-clavicular) during inspiration.  Suggestive of cholecystitis.

Rovsing's sign - Pain in R lower quadrant during L lower quadrant palpation. Suggests appendicitis.

Psoas sign - Pain on extension of R thigh.  Suggestive of retro-cecal appendicitis.

Obturator sign - Pain on internal rotation of the R thigh at the hip.  Suggestive of pelvic appendicitis.

Age specific

Infant– Contour is protuberant r/t immature abdominal

muscles– Skin has visible blood vessels until puberty– Abdomen will show resp movement– Peristalsis may be visible

Age specific considerations

Children– Have potbelly look until middle childhood

Pregnancy– Will obscure may structures

Elderly– Increases fat deposits on abd as compared to extremities.– Poor abd muscle tone– Less abd rigidity with acute abdominal conditions

Practice Exam Question

Your 76 year old pt is complaining of “gas Pains”. His abdominal looks larger than an hour ago. His umbilicus is now everted. His bowel sounds are Hyperactive. What condition may he be experiencing?

A. Hernia B. early intestinal obstruction C. late intestinal obstruction D. Gas

Rationale

B is the correct answer. Distention, pain and hyperactive bowel sounds are associated with early obstruction.

A is usually not accompanied by increased bowel sounds

C in late obstruction sounds are hypoactive D. gas may cause pain an mild distention but

should not increase bowel sounds