Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

Page 1 of 7

The Royal Beckham

and Victoria NHS TrustEmma Nate

Senior Practice

Development NurseNHS

Clinical ExaminationsAdults

Patient position and general inspection

Before beginning the examination, wash your hands and dry them thoroughly, or decontaminate your hands using alcohol-based hand sanitiser.

Before carrying out a physical abdominal examination, introduce yourself to the patient, explain the procedure and obtain their consent. This will help to establish a rapport and make the patient feel more relaxed. Offer the patient a chaperone. As the patient will be exposed from their chest to their knees, ensure their privacy by screening the bed or closing the door to their room. Make sure that the room is warm so that the patient does not get cold, and that the lighting is good as this will help you note abnormalities. Ask the patient to empty their bladder to make palpation of their abdomen more comfortable and to provide a urine specimen for testing.

Take a detailed history from the patient to highlight any specific problems and areas that you may need to explore further. Generally, the signs and symptoms noted in gastrointestinal disease can reflect disorders in the main abdominal organs. Symptoms such as pain, dyspepsia, dysphagia, vomiting, altered bowel habit or rectal bleeding can help focus your examination and assist you in making a diagnosis.

Take and record the patient’s pulse, temperature and blood pressure. Note any tachycardia and raised temperature which may indicate infection. A tachycardia on its own where the pulse is weak and thready may indicate bleeding.

An abdominal examination is conventionally conducted from the patient’s right side; this also makes it easy to determine the span of the patient’s liver.There are four aspects to a detailed examination:

• Inspection; • Auscultation;• Percussion; and• Palpation.

Ensure that you use appropriate PPE throughout, adhering to the latest national guidance; see the clinicalskills.net procedure, “Putting on and taking off PPE for COVID-19”.

Please lie flat with your arms placed loosely by your side and try to relax.

Abdominal examinationAnthony McGrath, Dean, School of Nursing and Midwifery, London South Bank University

©2021 Clinical Skills Limited. All rights reserved

Wash and dry your hands

Assist the patient to remove clothing as appropriate and help them onto the couch/bed, adjusting its height accordingly. Ask the patient to lie flat with their head on a pillow and their arms placed loosely by their side; this will help to relax their abdominal muscles. Slightly raise their knees, placing a pillow underneath to support them. Provide the patient with a sheet large enough to cover them from the chest to the knees, and move this aside as required during the examination. Ask the patient to point to any area of pain before beginning the examination. Carry out an initial general inspection, e.g., look for jaundice, abdominal distension and spider naevi as evidence of liver disease. Cachexia may indicate advanced disease or malignancy. Follow with a more detailed inspection of the face, chest, abdominal and pelvic areas. If there is space, stand at the base of the bed and note the symmetry of the abdomen, any peristalsis, and the colour and condition of the skin. Note any scars, as these are indicative of previous surgery. Likewise, note any asymmetrical movement of the abdomen, which may indicate the presence of a mass.

Sheet now is only covered to the knees

Inspect the eyes

Inspect the hands: (a) (b)

Examine the eyes. If a patient is jaundiced, this is best seen in the sclera of the eyes (as well as inside the mouth on the oral mucosa). Note any brownish green rings in the periphery of the cornea (Kayser-Fleischer rings) caused by excessive copper deposits—a sign of Wilson’s disease. Note the presence of any xanthelasma around the eyes indicating high cholesterol.

Examine the hands by looking for signs of palmar erythema (red palms). While it can be a normal finding, it is usually found in pregnancy and in chronic liver disease. A Dupuytren’s contracture is a visible and palpable thickening and contraction of the palmar fascia causing permanent flexion. This condition is associated with alcohol abuse but can also be found in manual workers’ hands.

Check the dorsal aspect of the hands. Note any nicotine staining. When inspecting the nails, note any pitting, ribbing and brittleness linked to malabsorption syndromes. Koilonychia (spoon-shaped nails) indicates iron deficiency anaemias; leuconychia or white nail occurs in liver failure or hypoalbuminaemia. Look at the fingers noting clubbing caused by inflammatory bowel disease or coeliac disease.

Clinical ExaminationsAdults

Abdominal examination Page 2

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Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

Inspect the mouth

Check around the patient’s mouth for angular stomatitis and note any halitosis; a faecal smell can be linked with bowel obstruction. Use a pen torch to look inside the mouth. Note if the tongue is dry as this may indicate dehydration. Look for pallor and any signs of jaundice. Note that on dark skin the face may appear grey.

(c)

Ask the patient to hold their arms outstretched with their wrists dorsiflexed for a minimum of 20 seconds to determine if they have asterixis (a liver flap)—an irregular coarse tremor occurring in liver failure. Note any needle marks in the arms, which may be clues to drug abuse and potential hepatitis.

Look at the abdominal profile: (a)

Observe the patient’s abdominal profile: normally, the abdomen is concave, symmetrical and moves gently with respiration. If the abdomen is distended, this may be due to one of the 5 F’s: flatus, faeces, fetus, fat or fluid (e.g., ascites—see inset). Bulging around scars may indicate the presence of an incisional hernia. Visible peristalsis can indicate obstruction. An aortic aneurysm may cause the presence of pulsation in the epigastric region.

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Clinical Examinations

Adults

Abdominal examination Page 3

Auscultate the abdomen

Auscultate the main arterial vessels: (a)

Percussion Percuss the abdomen

Place the bell of the stethoscope over the main arterial vessels of the abdomen to listen to the aorta (1), the renal arteries (2) and the iliac arteries (3).

Place the bell of the stethoscope over the abdominal aorta, at a point midway between the xiphisternum and the umbilicus, to listen for an aortic bruit. Listen for renal artery bruits on either side, at points that are 2.5 cm above, and lateral to, the umbilicus.

To carry out percussion, place one finger of your non-dominant hand on the surface of the skin and use one or two fingers of your dominant hand to percuss the finger placed over the skin.

It is important to percuss all four quadrants of the abdomen for dullness and resonance. Good percussion technique will allow you to assess the amount and distribution of gas in the abdomen. It will also allow you to determine the size of the liver and spleen.

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Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

(b)

Note discolouration in the abdominal wall. The seepage of blood-stained ascitic fluid into the subcutaneous tissue causes a bluish discolouration or ecchymosis in either the flanks (Grey Turner’s sign) or around the umbilicus (Cullen’s sign) and is seen in patients who have an acute haemorrhage. When looking at the umbilicus, note whether a hernia is present.

Xiphisternum Umbilicus

2.5cm

2.5cm

2.5cm2.5cm

(b)

Gas and fluid make gurgle and click sounds as they move through the bowel. Place the diaphragm of the stethoscope on each of the four quadrants of the abdomen: the upper left (1), upper right (2), lower left (3) and lower right (4). Listen for bowel sounds for 10–15 seconds in each quadrant. If nothing is heard, listen within that quadrant for up to 2 minutes (Innes et al., 2018).

Fluid

Air

Interface

The Royal Beckham

and Victoria

NHS Trust

Emma Nate

Senior Practice

Development Nurse NHS

Clinical Examinations

Adults

Abdominal examination Page 4

(b)

(c)

Instruct the patient to hold their finger over the lower border of the liver.

Percuss the intercostal spaces along the mid-clavicular line, working upwards until the percussion note becomes resonant again. This is the upper border of the anterior aspect of the liver.

Percuss and listen Shifting dullness

If you note a generalised swelling or distension of the abdomen, lay the patient on one side. Then as you percuss, listen for a change from a resonant to a tympanic sound, which indicates the interface of fluid and air.

Mark the upper level of dullness with your hand or finger. Roll the patient flat and see if the level shifts. If it does, this is called shifting dullness. Note that in ascites, there is central tympani and lateral dullness.

Page 4 of 7

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

(d)

You can now determine the approximate size of the liver.

Mid-clavicularline

Livermargin

Percuss to determine the size of the liver: (a)

On the right side of the abdomen, percuss the intercostal spaces along the mid-clavicular line up to the lower margin of the liver. At this point, the sound will change from resonance to dullness.

The Royal Beckham

and Victoria

NHS Trust

Emma Nate

Senior Practice

Development Nurse NHS

Clinical Examinations

Adults

Abdominal examination Page 5

(b) Gently palpate the aorta

To obtain the most information, palpate in two stages: lightly palpate to identify any tenderness then deeply palpate to detect deeper masses and to try to define any masses found previously. Gently palpate the aorta in the midline above the umbilicus for a pulsatile mass. If easily palpated, suspect aortic aneurysm. As you inspect the patient, note any bobbing of the patient’s head with each pulsation of the aorta (de Musset sign).

The Royal Beckham

and Victoria

NHS Trust

Emma Nate

Senior Practice

Development Nurse NHS

The Royal Beckham

and Victoria

NHS Trust

Emma Nate

Senior Practice

Development Nurse NHS

Light superficial palpation of the abdomen

Deep palpation of the abdomen

Gently and lightly palpate each quadrant of the abdomen to a 1–3 cm depth, starting away from the site of pain or tenderness. Make sure that your hand is flat on the patient’s abdomen and palpate each abdominal quadrant in turn using the palmar surface of the fingers to allow you to mould your hand to the shape of the abdominal wall.

Perform a deeper palpation of the abdomen by evenly pressing down 4–6 cm into the wall of the abdomen. Muscle rigidity along with distension is suggestive of peritonitis. As you palpate the abdomen, note any masses and if a mass is found, describe the site, size, shape and consistency. Note if it is tender or pulsatile (caused by the transmitted pulsation from the aorta or pulsatile swelling).

The Royal Beckham

and Victoria

NHS Trust

Emma Nate

Senior Practice

Development Nurse NHS

Rebound tenderness (in appendicitis)

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Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

The Royal Beckh

am

and Victoria

NHS Trust

Emma Nate

Senior Practic

e

Development Nurse

NHS

Palpation: (a)

Before palpating the patient’s abdomen, ensure the patient is supine. Ask them if their abdomen is painful and encourage them to point to where the pain is worst. Ask whether the pain radiates and about its onset and duration. Ensure that your hands are warm and tell the patient to inform you if it hurts when you begin to palpate.

Check for rebound tenderness by palpating the right iliac fossa, looking at the patient’s face to see if palpation is hurting or causing any discomfort. Note any tenderness which may be superficial, deep or rebound. Rebound tenderness occurs in peritonitis, and is caused by the movement of inflamed viscera against the parietal peritoneum. Note any guarding which is a voluntary muscle spasm to protect from pain.

Should the hand be �at on patient’s abdomen as described in the caption?

To palpate the liver, place your hand just lateral to the rectus muscle well below the border identified by percussion.

Rectus muscle region

Border identified by percussion

Costalmargin

Palpate the liver: (a)

Is your abdomen painful anywhere?

Clinical Examinations

Adults

Abdominal examination Page 6

Costalmargin

Spleen

Enlarged Spleen

Palpate the spleen: (a)

You cannot feel the normal spleen; it only becomes palpable when it has doubled or trebled in size. Ask the patient to take deep breaths, as this brings the spleen down so that it can be palpated.

Roll the patient towards their right side with their left arm hanging loosely in front of them. Work your examining hand gently up towards the left costal margin.

Start about 10 cm below the costal margin and work up towards the ribs. Use your fingertips, both hands or, if you prefer, the radial side of your index finger on one hand.

Page 6 of 7

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

Ask the patient to take a deep breath, then press your fingers inwards and upwards. At the height of the patient’s inspiration, slightly relax your inward pressure while maintaining the upward pressure. The liver should descend and, as it does so, the liver edge should slide under your fingers.

(c)

In healthy individuals, the liver edge can usually be palpated just below the costal margin; sometimes it may be difficult to feel. If the patient has an enlarged liver, you may be able to feel it in the abdominal cavity as the liver will enlarge downwards towards the right iliac fossa.

Enlarged liver

(d)

10cm

(b)

Enlarged spleen

(b)

The Royal Beckham

and Victoria

NHS Trust

Emma Nate

Senior Practice

Development NurseNHS

(c)

If the spleen is not palpable, percuss the area for splenic dullness–the spleen can be enlarged to the hypogastrium.

Left kidney Right kidney

Clinical Examinations

Adults

Abdominal examination Page 7

Palpate the kidneys: (a) (b)

The kidneys are difficult to feel. You need to do deep bimanual palpation to explore them by placing one hand under the patient’s back and the other on the front of their loin. Ask the patient to take deep breaths as you ballot the right kidney.

Asking the patient to breathe deeply, push up with your left hand into the renal angle. This will bring the kidneys between your hands. Feel the right kidney anteriorly with your right hand. Tenderness over the kidneys is a common sign of infection. The presence of a large kidney may indicate a tumour, polycystic kidney disease or hydronephrosis. Ballot the left kidney in the same way.The Royal Beckham

and Victoria

NHS Trust

Emma Nate

Senior Practice

Development Nurse NHS

Palpate the bladder Costovertebral angle tenderness: (a)

(b)

To assess further for kidney tenderness, check for costovertebral angle tenderness which may indicate pyelonephritis. Ask the patient to sit forward and place the palm of your hand flat over the renal angle. Then make a fist and strike a blow on your hand using moderate force.

Palpate for the bladder in the hypogastric area and, if a mass is found, percuss to confirm the presence of fluid. If the patient is suffering from urinary retention, you may feel a full bladder above the pubic symphysis. As you palpate, the patient will feel uncomfortable and will want to pass urine.

Perform the manoeuvre on each kidney in turn and assess the patient’s reaction. This action should not cause any pain or tenderness unless there is some inflammation of the kidney.

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Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

Patient Notes ? X

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General Notes

Mr McDonald presented today with a 3-day history of vomiting. Today he vomited blood and his eyes appear jaundiced. He has abdominal distension. Liver flap noted. History taken and documented in medical notes.Physical examination undertaken with Mr McDonald's consent. Chaperone offered but declined by Mr McDonald.

Allergy Notes

Documentation

Ask the patient to dress and make sure that they are comfortable. Advise the patient of the clinical findings and discuss the next steps. Decontaminate your hands and document your findings in the patient’s notes.