NUR 103Health Assessment

The Abdomen

Objectives:

• Define terminology related to assessment of the abdomen.

• Describe anatomy and physiology of abdomen.• Identify equipment.• Identify positioning.• Identify techniques.• Explain the process of performing an assessment of the

abdomen.• Recognize normal and abnormal assessment data.• Differentiate between normal and abnormal assessment

data.

Terminology

• Abdomen- a large oval cavity extending from the diaphragm down to the brim of the pelvis.

• Aneurysm- defect or sac formed by dilation in artery wall.• Anorexia- loss of appetite.• Ascites- abnormal accumulation of serous fluid within the peritoneal

cavity.• Borborygmi- loud gurgling bowel sounds- inc. motility or

hyperperistalsis.• Bruit- blowing, swooshing sound heard through stethoscope when

artery is partially occluded.• Cecum- first or proximal part of large intestine.• Cholecystitis- inflammation of the gallbladder.• Costal margin- lower border of rib margin formed by dedial edges of

8th, 9th, and 10th ribs.• Costovertebral angle (CVA)- angle formed by the 12th rib and

vertebral column on posterior thorax, overlying kidney.• Diastasis recti- midline longitudinal ridge in abdomen, separation of

abdominal rectus muscles.

• Dysphagia- difficulty swallowing.• Epigastrium- name of abdominal region between the

costal margins.• Hepatomegaly- abnormal enlargement of liver.• Hernia- abnormal protrusion of bowel through weakening

in abdominal musculature.• Inguinal ligament- ligament extending from pubic bone to

anterior superior iliac spine, forming lower border of abdomen.

• Linea alba- midline tendinous seam joining the abdominal muscles.

• Paralytic ileus- complete absence of peristaltic movement.

• Peritoneal friction rub- rough grating sound heard through stethoscope over site of peritoneal inflam.

• Peritonitis- inflam. of peritoneum.

• Pyloric stenosis- congenital narrowing of pyloric sphincter, forming outflow obstruction of stomach.

• Pyrosis- (heartburn) burning sensation in upper abdomen, due to reflux of gastric acid.

• Rectus abdominis muscle- midline abdominal muscles extending from rib cage to pubic bone.

• Scaphoid- abnormally sunken abdominal wall.• Splenomagaly- abnormal enlargement of spleen.• Striae- (linia ablicantes)- silvery white or pink scar.• Suprapubic- name of abdom. Region just superior to pubic bone.• Tympany- high-pitched, musical, drumlike percussion note heard when

percussing over stomach and intestine.• Umbilicus- depression on abdom. Marking site of entry of umbilical cord.• Viscera- internal organs.• Solid viscera- characteristic shape (liver, pancreas, spleen, adrenal

glands, kidneys, ovaries, and uterus). • Hollow viscera- shape depends on contents (stomach, gallbladder, small

intestine, colon, and bladder).

Anatomy of the AbdomenDivided into 4 quadrants

Right upper quadrant:LiverGallbladderDuodenumHead of PancreasRight kidney and adrenalHepatic flexure of colonPart of ascending & transverse colon

Left upper quadrant:StomachSpleenLeft lobe of liverBody of pancreasLeft kidney & adrenalSplenic flexure of colonPart of transverse & descending colon

Right Lower Quadrant:CecumAppendixRight ovary and tubeRight ureterRight Spermatic cord

Left Lower Quadrant:Part of descending colonSigmoid colonLeft ovary and tubeLeft ureterLeft spermatic cord

Midline:AortaUterus (if enlarged)Bladder (if distended)

The Right Quadrant of the Abdomen:The Liver

The liver is located in the upperright portion of the abdominal Cavity, just below the diaphragm.Partially surrounded by the ribs, Extends from the level of fifth Intercostal spaceto lower margin of the ribs.

Gallbladder

The gallbladder is a pear-shaped sac located in adepression on theInferior surface of the right hepatic lobe.

Duodenum

The duodenum is part of the smallIntestine. Approx. 25 cm Long and 5 cm in diameter. It passes in front of the right kidneyAnd the upper three lumbar vertebrae.

Right KidneyThe kidney is a reddish brown, bean shapedOrgan with a smooth surface. 12 cm long, 6 cm wide, 3 cm thick in adult. The right kidney lies on the right side ofthe vertebral column in a depression highOn the posterior wall of the abdominal cavity (retroperitoneal).Right kidney is lower than Left kidney.

Head of pancreas

The pancreas is a soft, lobulated gland located behind the stomach. It extends horizontally across the posterior Abdominal wall with its head in the C-shaped curve of the duodenum and its tail against the Spleen.

Hepatic flexure of colon, part of ascending and transverse colon:

Ascending-Portion of the large Intestine that passesUpward on the rightSide of the abdomen From the secum to theLower edge of the liver.Transverse- extends across Abdomen from right to left below Stomach.

Left Upper Quadrant:

Digestive organ located between the esophagus and the small intestine.

Stomach: The Spleen:

A soft mass of lymphaticTissue on posterolateralWall of abdominal cavity,Immed. Under diaphragm.Lies obliquely, with long axisBehind and parallel to 10th rib. Lateral to midaxillary line.

Left lobe of liver:Body of pancreas:Left kidney and adrenalSplenic flexure of colonPart of transverse and Descending colon

Continuation of left quadrant of abdomen:

Right Lower Quadrant of Abdomen

• Cecum

• Appendix

• Right ureter

• Right spermatic cord• Right ovary and tube

Left Lower Quadrantof the Abdomen:

Part of descending colonSidmoid colon

Left ovary and tubeLeft ureter

Left Spermatic cord

MidlineAnatomy of Abdomen:

Aorta

Uterus (if enlarged)

Bladder ( if distended)

EQUIPMENT

• Proper lighting: include strong overhead light and secondary stand light.

• Stethoscope

• Small centimeter ruler

• Skin-marking pen

• Alcohol swab (to clean endpiece)

Positioning:•Position the person supine, with head on a pillow, knees bent or on pillow, and arms at sides or across the chest.Note: Discourage person from placing armsOver the head because this tenses abdom.Musculature.

Techniques:

• Provide strong lighting• Have person empty bladder• Keep room warm to avoid chilling & tensing of muscles• Position person supine• Warm stethoscope and hands to avoid abdom. Tensing.• Inquire re: painful areas, examine such area last to avoid

musculature guarding.• Finally, learn distraction tech. Enhance muscle relaxation

through breathing exercises, emotive imagery, low, soothing voice, allowing person to relate abdominal hx while you palpate.

Inspection:

Inspection of abdomen:• Normal Findings:

Contour

1. Stand on person’s right side, look on abdomen.

2. Your head should be slightly higher than abdom.

3. Determine profile from rib margin to pubic bone. Contour describes nutitional state. Normal ranges from flat to rounded.

• Abnormal Findings:

3. Scaphoid abdomen, protuberant abdomen, abdominal distention.

Symmetry of Abdomen• Normal Findings:1. Shine a light across abdom.

toward you, or shine lengthwise across person.

2. Abdomen should be symmetric bilaterally.

3. Even small bulges are highlighted by shadow.

4. Step to foot of examination table to recheck symmetry.

5. Ask person to take deep breath-further highlight any change. Abdom. Should stay smooth and symmetric.

• Abnormal Findings:

2. Bulges, masses3. Hernia- protrusion of abdom.

Viscera through abnormal opening in muscle wall.

Note any localized bulging.Hernia, enlarged liver or spleen may

show.

Inspection of Umbilicus:

• Normal Findings:

1. Normally at midline, inverted, no sign of discoloration, inflam., or hernia,.

Becomes everted and pushed upward with pregnancy.

• Abnormal Findings:

1. Everted with acites, or underlying mass.

2. Deeply sunken with obesity.

3. Enlarged and everted with umbilical hernia.

4. Bluish periumbilical color occurs with intraabdominal bleeding

(Cullen’s Sign)

Inspection of skin• Normal Findings:1. Surface smooth, even,

homogeneous color. 2. Striae- pink, or blue, then silvery

white pigment changes.3. Moles-circumscribed brown

macular or papular areas.4. No lesions present. May have well-

healed surgical scar, draw location in pt. record, indicating length in cm.

5. Veins usually not seen, fine venous network may be visible in thin persons.

6. Good skin turgor- healthy nutrition.Pinch up fold of skin, release to note

skin’sImmediate return to original position.

• Abnormal Findings:1. Redness with localized

inflammation, jaundice, Skin glistening and taut (ascites).

2. Striae look purple-blue-Cushing’s Syndrome (excess adrenocortical hormone causes skin to be fragile).

3. Unusual color or change in shape of mole. Petechiae.

4. Cutaneous angiomas (spider nevi) occur with portal HTN or liver disease.

5. Lesions, rashes. Prominent, dilated veins- portal HTN, cirrhosis, ascites, or vena caval obstruction. Veins more visible –malnutrition due to thinned adipose tissue.

Pulsation or movement:

• Normal Findings:

1. Pulsations normally seen from aorta beneath skin in epigastric area.

2. Respiratory movement in abdomen (males).

3. Waves of peristalsis in very thin persons.

(ripple slowly & obliquely across abdom.)

• Abnormal Findings:

1. Marked pulsations of aorta occurs with widened pulse pressure (HTN, aortic insuff., thyrotoxicosis) & aortic aneurysm.

3. Marked visible peristalsis, with distended abdomen- intestinal obstruction.

Inspection of abdomenHair distribution, Demeanor

• Normal Findings:

1. Pubic hair growth normally diamond shape in adult males, inverted triangle shape in females.

2. Demeanor- comfortable person relaxed on exam. Table, a benign facial expression, slow, even resp.

• Abnormal Findings:

1. Patterns alter with endocrine or hormone abnormalities, chronic liver diseases.

2. Restlessness, constant turning to find a comfortable position occur with colicky pain of gastroenteritis or bowel obstruction.

Auscultation of Abdomen

1. Use diaphragm endpiece- Bowel sounds are high pitched.

2. Hold stethoscope lightly against skin (pushing too hard may stim. More bowel sounds.

3. Begin in RLQ at ileocecal valve area (bowel sounds are almost always present here normally).

Note: Perform auscultation next because percussion and palp.can increase peristalsis, which could give false interpretationOf bowel sounds.

Bowel Sounds and Vascular Sounds:

Bowel Sounds

• Normal Findings:1. Note character of bowel

sounds. Wide range of normal sounds, irreg. (5-30 times/min.)

2. Borborygmus- type of hyperactive bowel sound fairly common. (when you feel your stomach growling).

3. Note: you must listen for 5 min. before deciding if BS are completely absent.

• Abnormal Findings:1. Two distinct abnorm.

sounds:A. Hyperactive- loud, high-

pitched, rushing, tinkling sounds-signal inc.motility.

B. Hypoactive-or absent sounds.

Vascular Sounds

• Normal Findings:

1. As you listen, note presence of vscular sounds or bruits.

2. Using firmer pressure, check over aorta, renal arteries, iliac, and femoral arteries. No sound is normal.

• Abnormal Findings:

1. Note location, pitch, and timing of vascular sound.

2. Systolic bruit is pulsatile blowing sound, occurs with stenosis or occlusion of artery.

3. Venous hum, peritoneal friction rub are rare.

Femoralartery

Vascular Sounds

Percussion of abdomen:General tympany, liver span,

splenic dullness.

Percussion:

• To assess relative density of abdominal contents, to locate organs, and to screen for abnormal fluid or masses.

General Tympany• Normal Findings:

1. First, percuss lightly-all four quad. to determine amt. tympany & dullness.

2. Tympany should predominate.

• Abnormal Findings:

1. Dullness occurs over distended bladder, adipose tissue, fluid, or mass.

2. Hyperresonance is present with gaseous distention

Liver Span• Normal range of findings:1. Next, map out boundaries of certain

organs. 2. Measure ht. of liver in right midclavicular

line.3. Begin in area of lung resonance, percuss

down interspaces until sound changes to dull quality.

4. Mark the spot (usually in 5th intercostal space. Then find abdom. Tympany & percuss u midclavicular line. Mark where sound changes from tympany to dull sound, normally at right costal margin.

5. Measure distance between two marks; normal liver span in adult ranges from 6-12 cm. Height of liver span correlates ht. of person, taller have longer livers.

• Abnormal Findings:

2. Enlarged liver span indicates liver enlargement or hepatomegaly.

3. Accurate detection of liver borders is confused by dullness above the 5th intercostal space (Lung disease, e.g.,pleural effucion or consolidation.) Accurate detection at lower border is confused when dullness is pushed up with ascites or pregnancy or gas distention in colon.

Normal range of findings, cont’d.

• One variation occurs with chronic emphysema, which the liver is displaced downward by hyperinflated lungs. Although dull percussion is noted well below right costal margin, the overall span is still WNL’s.

• Clinical estimation of liver span is important to screen for hepatomegly & to monitor changes in liver size. Measurement is a gross estimate, liver span may be underestimated because of inaccurate detection of upper border.

• Scratch test- final tech. may help define liver border when abdom. Is distended or abdom. Muscles are tense.

Splenic Dullness• Normal Findings:1. Spleen is obscured by stomach

contents, may locate by percussing for dull note from 9th-11th intercostal space behind left midaxillary line.

2. Now, percuss in lowest interspace in left anterior axillary line. Tympany should result. Ask person to take deep breath, normally, tympany remains through full inspiration

• Abnormal Findings:1. Dull note forward of midaxillary

line indicates enlargement of spleen (mononucleosis, trauma, infection).

2. In this site, anterior axillary line, change in percussion from tympany to dull sound wit full inspiration is positive spleen percussion sign, indicating splenomagaly. This method will detect mild to mod. Splenomegaly before spleen becomes papable (mononucleosis, malaria, or hepatic cirrhosis).

Costovertebral Angle Tenderness• Normal Findings:1. Indirect fist percussion

causes tissues to vibrate instead of producing a sound.

2. To assess the kidney, place one hand over the 12th rib at the CVA on the back. Thump that hand with the ulnar edge of other fist. No pain elicited.

• Abnormal Findings:1. Sharp pain occurs with

inflammation of kidney or paranephric area.

Special Procedures:Ascites

• Fluid Wave:1. First, test for a fluid wave by

standing on person’s right side. Place ulnar edge of another examiner’s hand on abdomen in midline. Place left hand on person’s right flank. With right hand, reach across abdomen and give the left flank a firm strike. If ascites is present, the blow will generate a fluid wave through the abdomen, & feel distinct tap on left hand. If distended from gas or adipose tissue, no change.

• Shifting Dullness:1. In a supine position, ascitic fluid

settles by gravity into the flanks, displacing air-filled bowel upward. You will hear a tympanitic note as yu percuss over the top of abdomen because gas-filled intestines float over the fluid.

2. Then percuss down side of abdomen. If fluid is present, the note will change from tympany to dull as you reach its level.

3. Now turn pt. to right side (roll toward you). Fluid will gravitate to dependent side. Begin percussing upper side of abdomen and move downward. Sound changes from tympany to dull sound as you reach fluid level. This level of dullness is higher, upward toward the umbilicus.

Palpation of Abdomen

1. Palpation is performed to judge the size, location, & consistency of certain organs & to screen for an abnormal mass or tenderness.

Technique for palpation

1. Bend the person’s knees.2. Keep palpating hand low & parallel to abdomen.3. Teach pt. to breathe slowly (in through nose, out

through mouth).4. Keep your own voice low & soothing. Conversation

may relax the pt.5. Try “emotive imagery”.6. Keep pt.’s hand under your finger curled over his/her

fingers for very ticklish person. People are not ticklish to themselves.

7. Alternatively, perform palpation just after auscultation. Keep stethoscope in place & use stethoscope until pt. is used to being touched.

Light palpation:• Normal Findings:1. Begin with light palpation.2. With first four fingers close

together, depress skin about 1 cm. Make gentle rotary motion, sliding fingers & skin together.

3. Lift fingers, do not drag them, & move clockwise to next location around abdom.

4. Objective here is not to search for organs but to form overall impression of skin surface & superficial musculature.

5. Save exam of identified tender areas until last.

6. Determine if voluntary muscle guarding & involuntary rigidity.

• Abnormal Findings:1. Muscle guarding2. Rigidity3. Large masses4. Tenderness5. Involuntary rigidity is constant

board like hardness of muscles.

Deep palpation• Normal Findings:1. Same tech. as light palp., but

push down 5-8 cm (2-3 in.) moving clockwise, exploring entire abdomen.

2. To overcome resistance of very large or obese abdomen, use bimanual tech.

3. Place two hands on top of ea. Other. Top hand does pushing; bottom hand is relaxed, concentrating on sense of palpation.

4. Note location, size, shape, consistency (soft, firm, hard), surface (smooth, nodular), Mobility (including movement with respiration), pulsatility, tenderness

• Abnormal Findings:1. Tenderness occurs with local

inflammation, with inflammation of peritoneum or underlying organ, & with an enlarged organ whose capsule is stretched.

2. Abnormal enlargement.3. Tenderness.4. Masses.

Palpation of Liver• Normal Findings:1. Place left hand under

person’s back parallel to 11th & 12th ribs and lift up to support abdominal contents.

2. Place deeply down & under right costal margin.

3. Ask person to take a deep breath.

4. Normal to feel edge of liver bump fingertips as diaphragm pushes it down during inhalation. Feels like firm regular ridge. May not be palpable, may feel nothing.

• Abnormal Findings:1. Except for depressed diaphra,

l liver palpated more than 1-2 cm below right costal margin is enlarged.

2. Record number in cm it descends & note consistency (hard, nodular), and tenderness.

Palpation of spleen• Normal Findings:1. Normally spleen is not palpable,

must be enlarged three times its normal size to be felt.

2. To find, reach your left hand over abdomen & behind the left at 11th & 12th ribs. Lift up for support.

3. Place right hand obliquely on LUQ with fingers pointing toward left axilla & just inferior to rib margin.

4. Push hand deeply down & under left costal margin & ask person to take deep breath. You should feel nothing firm.

• Abnormal Findings:1. Spleen enlarges with

mononucleosis and trauma.2. Describe number of cm it extends

below left costal margin.3. When spleen is enlarged, it slides

out & bumps fingertips. Can grow so large that it extends into lower quadrants.

4. May roll person onto right side to displace spleen more forward & downward.

Palpation of kidneys• Normal Findings:1. Search for right kidney by placing

hands together in a “duck-bill” position at person’s right flank.

2. Press two hands together firmly & ask person to take deep breath. In most people, feel no change. Occ. You feel lower pole of right kidney as round, smooth mass slide between fingers. Either is normal.

3. Left Kidney sits 1 cm higher than right, not palpable normally. Locate by reaching left hand across abdom. & behind left flank for support. Push right hand deep into abdom. And ask person to breathe deeply. You should feel no change with inhalation.

• Abnormal Findings:1. Enlarged kidney2. Kidney mass

Palpation of aorta• Normal Findings:

1. Using opposing thumb & fingers, palpate aortic pulsation in upper abdomen slightly to left of midline.

2. Normally- 2.5-4 cm wide in adult, pulsates in anterior direction.

• Abnormal Findings:

1. Widened with aneurysm

2. Prominent lateral pulsation with aortic aneurysm.

Special procedures for abdominal palpation:

• Normal Findings:

1. Rebound tenderness:

(Blumberg’s Sign)-Assess when person reports abdom. Pain or when elicit tenderness during palpation.

Hold hand perpendicular to abdom., push down slowly and deeply, lift up quickly. A normal, or negative response is no pain on release of pressure.

• Abnormal Findings:

1. Pain on release of pressure confirms rebound tenderness, reliable sign of peritoneal inflammation.

Murphy’s Sign (Inspiratory arrest)

• Normal Findings:1. Normally, palpating

will cause no pain. 2. Ask person to take

deep breath. Hold fingers under liver border.

3. A normal response is to complete deep breath without pain.

• Abnormal Findings:1. Positive test: as

descending liver pushes inflamed gallbladder onto examining hand, person feels sharp pain & abruptly stops inspiration midway.

Iliopsoas Muscle Test

• Normal Findings:1. Perform when acute

abdom. Pain of appendicitis is suspected.

2. With pt. in supine pos., lift right leg straight up, flexing at hip, then push down over lower part of right thigh as person tries to hold leg up.

3. Negative test when pt. feels no pain

• Abnormal Findings:• When iliopsoas muscle is

inflamed (Inflamed or perforrated appendix), pain is felt in right lower quadrant.

Obiturator Test

• Normal Findings:• Test done when

appendicitis is suspected.• With person supine, lift

right leg, flexing at hip, and 90 degrees at knee. Hold ankle & rotate leg internally & externally.

• Negative or normal is no pain.

• Abnormal Findings:

1. Perforated appendix irritates the obturator muscle, producing pain.

Developmental Considerations:• Normal Findings in the

infant, child, adolescent, and aging adult:

• Abnormal Findings:• Scaphoid shape occurs with

dehydration in infant and child. Dilated veins.

• Only one artery in umbilical cord in infant, inflammation, drainage after cord falls off.

• Under 7 yrs., absence of abdom. Resp. occurs with inflammation of peritoneum.

• Abdom. Rigidity with acute abdom. Conditions less common in aging persons.

• Acute abdom, aging person complains of less pain than younger person.