abdominal assessment 3

8/3/2019 Abdominal Assessment 3

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PHYSICAL ASSESSMENT OF THEABDOMEN

Dr. Beverly Fineman

Nursing 309


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OBJECTIVES

At the end of this class, the student will be ableto:

Identify landmarks for the abdominalassessment

Correctly perform techniques of inspection,auscultation, percussion and palpation

Differentiate normal from abnormal findings

Document findings


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Overview of abdominalstructure. large oval cavity

extends from diaphragm tosymphysis

viscera: solid and hollow


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Landmarks for theabdominal examination four quadrants

nine sections bony landmarks

muscles


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More landmarks

Bony landmarks on the anterior body include:

xiphoid process of sternum

costal margin, midline, umbilicus, anterioriliac spine, pouparts ligament, superior

margin of pubis

Posterior landmark costovertebral angle


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Abdominal assessment Preparing the exam room

preparing the patient

positioning the examiner


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Assessment

Techniques

inspection

skin: color, scars, veins, lesions,umbilicus

umbilical hernia, bleeding,

inflammation


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Continued inspection contour of the abdomen:flat,rounded,

protuberant,scaphoid

symmetry

enlarged organ

masses

peristalsis,pulsation,distention


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distention

-Definition: unusual stretching of

abdominal wall

note position of umbilicus note portion of abdomen that is

distended

reasons for distention:flat(obesity),

flatus(gas), feces, fluid,

fetus(pregnancy or tumor)


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Auscultation

Where it occurs in abdominalassessment

listening for bowel sounds toassess motility

normal sounds

abnormal sounds how and where to listen


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Auscultation continued

Auscultation performed before

palpation and percussion

Use diaphragm of stethoscope Listen to bowel sounds

Normal sounds are clicks and

gurgles, irregular, 5-30 times per minute Influenced by digestion


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More on Auscultation

Increased bowel sounds are due tohypermotility of peristalsis

Decreased are due to paralytic ileus orperitonitis

intestinal obstruction can present withincreased or decreased sounds


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Additional Sounds

Always listen in hypertensive patient

Bruits:

Bruits are low pitched, vascular sounds, resemblingmurmur

Caused by partially obstructed artery turbulence

Listen in epigastrum and each upper quadrant

Listen in costovertebral angle(with patient seated) Listen over aorta, iliac arteries, femoral arteries

Arterial insufficiency in legs


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PERCUSSION

Assessment technique used toassess size and density of organs

in the abdomen Examples: used to measure size

of liver or spleen


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More on percussion

Used to identify masses

Used to identify air in stomach or in bowel

Used alone or in conjunction with palpation or tovalidate palpatory findings

Orient yourself to the abdomen by lightlypercussing all 4 quadrants for tympany or

dullness tympany usually predominates due to gas in

the bowel


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Percussion Continued

Dullness may be present due to feces orfluid or over organs or a solid mass

Develop a specific percussion route and

stick to it. To percuss the liver or estimate its size:

in right midclavicular line, start below theumbilicus with tympany and percuss

upward toward liver dullness. Mark to indicate the liver border


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Liver Percussion

In the right midclavicular line, percuss down fromlung resonance to liver dullness. This indicates

the lower border of the liver Mark this and measure between the two lines

This is the height of the liver


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More about percussion

Percussion provides most accurateclinical measurement of liver size as a

gross measurement


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Percussing the spleen

Where is the spleen located?

in the curve of the diaphragm just posterior

to the left midaxillary line When the spleen enlarges, it does so

anteriorly, downward and medially. This willreplace the tympany of the stomach and

colon with dullness


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Tricks to Assessing the Spleen

Percuss in the lowest interspace in the leftanterior axillary line for tympany.

Ask the patient to take a deep breath andpercuss on inspiration.

the percussion note should remain tympanic

A change to dullness suggest spenomegally

This is known as a positive splenic percussionsign


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Another trick

Percuss in several directions awayfrom tympany or resonance todullness

outline edges

a large dull area suggestssplenomegally


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Other Findings

To differentiate amongst fat, gas, tumoror ascites:

fattympany with scattered areas ofdullness

gasdistention with tympany

tumordullness with tympany

ascitesfluid seeks the lowest pointin the abdomen. Flanks are dull topercussion with tympanic center. Thereis a protuberant abdomen with bulgingflanks


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Assessing for Ascites

With patient lying supine, findtympany in center of abdomen

From center of abdomen, percussoutward in several directions todenote dullness

To test for shifting dullness, ask

patient to turn to one side, thenpercuss from tympany to dullness

fluid will sink to lowest point


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More on ascites

Assess for fluid wave

Puddle sign


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Assessing for kidney tenderness Find the costovertebral angle

This is the angle formed by the lowerborder of the 12th rib and the transverveprocesses of the upper lumbar vertebrae

Place left hand flat in this area on oneside, hit the hand sharply with the fist ofthe other. Patient will admit totenderness if present.

Repeat on the other side


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PALPATION

Used to assess muscle tone, tenderness, fluid,organs

May be light or deep

Use pads of fingertips in light dipping motionsand avoid short jabs


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Palpation cont.

To differentiate voluntary from involuntaryresistance: rectus muscle will relax with

expiration. Palpation is light or deep

Deep palpation used to define and delineateorgans or abdominal masses.

Use palmar surface of fingers and feel in allfour quadrants


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Deep palpation

If masses are felt, note: location, size, shalpe,consistency, tenderness, pulsations, mobility

with respiration or with hand. If patient is obese or rigid, use 2 hands to

palpate

Place one on top of other and feel with lower

hand


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The bladder

Bladder percussion is unnecessaryunless there is a suspicion ofurinary retention

Palpate above the symphysis

An empty bladder is not palpable


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Palpation of the liver

Stand on patients right side

Place left hand behind patient parallel to andsupporting 11-12th ribs

Patient should relax

Press your left hand forward and place yourright hand on abdomen with fingertips below

lower edge liver dullness Press in and up while patient takes deep

breath; if palpable, liver should come down


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Palpation cont.

Liver hook

Kidney: not palpable in normal

adult May be able to feel lower right

kidney pole in very thin person


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The spleen

The spleen is usually not palpable

From patients right side, reach over and

around under patient with your left hand Place right hand below left costal margin and

press in toward spleen. Ask patient to takedeep breath---will feel if palpable


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Assessing for peritoneal

irritation Ask patient to cough. Palpate lightly with one

finger over area of pain produced by cough

Test for REBOUND TENDERNESS: pressfinger in firmly and slowly then quicklywithdraw. Rebound tenderness mean thewithdrawal has caused the pain--- not the

pressure Other: Psoas sign and Obturator sign,

cutaneous hyperesthesia


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Assessing the Aorta

Press firmly deep in upper abdomen slightly toleft of midline.

Feel for aortic pulsations Determine width of aorta by pressing deeply on

either side of aorta

What is the normal width of the aorta?

If pulsatile mass is found, feel for femoral pulseswhich may be dimished.


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This concludes the

examination of theabdomen


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Examination of the anus

and rectumThis information is sometimes

included with the abdominalassessment and at times

with assessment of themale and female genitalia.

For our purposes, we areincluding it here


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General Principles

Anal canal is outlet of GI tract

3.8cm long

Merges with rectal mucosa @ anorectaljunction

Sensory nerves in anal area responsible forpain due to trauma


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Sphincters

2 concentric layers of muscle that keep analcanal closed

Internal sphincter

under involuntary control by autonomicnervous system

External sphincter

surround internal sphincters

under voluntary control Intersphincteric groove: palpable separation

between internal and external sphincter


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MORE THAN YOU WANT TO

KNOW: Anal columns - -folds of mucosa

extend vertically from rectum and

end in anorectal junction Can be seen with scope

Each column contains and arteryand vein


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hemorrhoids

With increased venous (portal) pressure, veincan enlarge.

this is a hemorrhoid or a varicosity

External hemorrhoids occur below theanorectal junction

itch and bleed with defecation

painful and swollen with thrombosis resolve and leave flabby skin top around

anal opening.


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continued

Internal hemorrhoids originate above anorectaljunction

covered with mucosa

may appear as red mass with pressure(valsalva)

abdominal assessment 3

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