assessment of the abdomen
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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
Collecting SUBJECTIVE DATA
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
Collecting SUBJECTIVE DATA
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
Nursing history to determine
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
Nursing history to determine
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
Nursing history to determine
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
Nursing history to determine
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
Nursing history to determine
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
Nursing history to determine
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
Collecting OBJECTIVE DATA
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
Collecting OBJECTIVE DATA
Normal Variations of Contour with Age Infant-toddler
◦Protuberant Preschool age child
◦Rounded, lumbar lordosis School age child
◦Scaphoid Adolescent / adult
◦Varied
Collecting OBJECTIVE DATA
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
Collecting OBJECTIVE DATA
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
Collecting OBJECTIVE DATA
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
Collecting OBJECTIVE DATA
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
Collecting OBJECTIVE DATA
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.
Collecting OBJECTIVE DATA
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.
Collecting OBJECTIVE DATA
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
Collecting OBJECTIVE DATA
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.
Collecting OBJECTIVE DATA
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
Collecting OBJECTIVE DATA
◦ 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
Collecting objective data
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
Collecting objective data
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.
Common Abnormal Abdominal Findings
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.
Common Abnormal Abdominal Findings
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.
Common Abnormal Abdominal Findings
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
Common Abnormal Abdominal Findings
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