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The abdomen is a large oval cavity extending from the diaphragm down to the brim of the pelvis.
1. Borders
2. Abdominal muscles

1. Bordered in back by the vertebral column and paravertebral muscles, at the sides and front by the lower rib cage and abdominal muscles
2. 4 layers of large, flat muscles form the ventral abdominal wall (rectus abdomninis, external oblique, internal oblique, transversus)

Surface landmarks of the Abdomen

Internal Anatomy Solid Organs (Viscera)
- Maintain characteristic shape

- Liver
- Spleen
- Pancreas
- Kidneys
- Adrenals
- Ovaries
- Uterus

Internal Anatomy Hollow Organs
- Shape depends on the contents
- Not usually palpable except distention

- Stomach
- Gallbladder
- Small intestine
- Colon
- Bladder

Internal Organs

Internal Organs

1. Liver location?
2. Palpable?
3. Kidney's palpable?
4. Ovaries palpable?

1. fills most of the right upper quadrant and extends over to the left midclavicular line
2. lower edge is palpable
3. right kidney normally can be palpable
4. ovaries normally palpable only on bimanual examination during pelvic exam

1. Spleen location?
2. Palpable?

1. soft mass of lymphatic tissue on the posterolateral wall of the abdominal cavity immediately under the diaphragm and lies obliquely with its long axis behind/parallel to the 10th rib
2. not normally palpable, if enlarged its lower pole moves downard and toward the midlne

The Pancreas is?

soft, lobulated gland located behind the stomach, stretches obliquely across the posterior abdominal wall to the left upper quadrant

Kidneys are?

bean shaped, are retroperitoneal or posterior to the abdominal contents, protected by the posterior ribs and musculature.

Costovertebral angle?

The 12th rib forms an angle with the vertebral column

Because of the placement of the liver, the right kidney?

rests 1 to 2 cm lower than the left kidney and sometimes may be palpable

Four Quadrants

Picture of kidneys

Anatomic locations of organ and quadrant

Vessels?

Aorta is just left of the midline in upper part of the abdomen, bifurcates into the right and left common iliac arteries opposite of the 4th lumbar, they become left and right femoral arteries. all palpable.

Function of the GI

Secretion, digestion, absorption, motility, elimination

Alimentary Tract

- mouth
- esophagus
- stomach
- small intestine: movement, digestion, absorption
- large intestine: colon & rectum: movement, absorption, elimination

Accessory organs

- liver: storage, protection, metabolism
- gallbladder: collects, concentrates, stores bile from liver, releases bile into duodenum
- pancreas: exocrine and endocrine
- spleen

Urinary Tract

- kidney: regulatory and hormonal functions
- ureters
- bladder

Refered Abdominal Pain

Developmental Considerations
Infants and Children

- digestive organs begin to form at 4 weeks gestation
- Infants abdomen less muscular, easy to palpate organs

Developmental Considerations
Pregnant Female

- abdominal muscles lose tone
- stomach displaced upwards: GERD
- peristaltic activity decreased and water absorption increased: constipation
- hemorrhoid formation occurs
- bladder compression
- decreased gallbladder emptying
- bowel sounds diminished-intestines displaced upward and posteriorly

Developmental Considerations
Elderly

- aging causes adipose tissue to redistribute away from face and extremities and to abdomen and hips
- liver size decreases leading to altered metabolism
- esophageal emptying delayed
- altered intestinal motility
- decreased gastric secretion
- delayed colon and rectal emptying: constipation

Subjective Data
1. Appetite
2. Dysphagia
3. Food intolerance
4. Abdominal pain
5. Nausea/Vomiting
6. Bowel habits
7. Past abdominal hx
8. Medications
9. Nutritional assessment

1. anorexia=loss of appetitie
2. occurs with disorder of throat/esophagus
3. lactose intolerance, pyrosis=heartburn
4. visceral=dull, general, poorly localized, referred pain
5. common with medication, GI disease, early pregnancy
6. black tarry stool=GI bleed, nontarry black=iron meds, gray stool=hepatitis
7. ulcer, gallbladder, hepatitis, jaundice, appendicitus, colitis, hernia
8.peptic ulcer caused by NSAIDS

ROS for intants and children

- weight gain in infants
- passage of first stool
- appetitie and feeding hx
- birth weight

ROS for Elderly

- groceries
- eat alone
- bowel patterns
- laxative use
- incontinence
- dietary intake

Preparation for Objective Data
- Use good lighting
- Enhance abdominal wall relaxation:

- empty bladder
- keep room warm
- position supie, head on pillow, arms to sides relaxed
- avoid abdominal tensing, keep hands, fingers, tools warms
- use distraction, breathing exercises, emotive imagery, low soothing voice, patient talk while palpating

Inspection:
1. check contour profile from rib margin to pubic bone
2. check symmetry
3. check umbilicus

1. flat, rounded, protuberant, scaphoid
2. bulges, masses or hernia
3. central without displacement, inverted or protruded slightly, free of inflammation, swelling, or bulges that indicate hernia, color should be consistent with body

Cullens sign?

Bluish periumbilical color occurs with intraabdominal bleeding

Inspection of Skin - Abnormal on back
- surface is smooth, even, homogenous color
- striae is common pigment
- pigmented nevi, brown macular or papular areas are common on abdomen
- surgical scars, draw its location on record in cm
- veins usually not seen, fine venous network ok
- pulsations or aorta, peristalsis ok
- pattern of pubic hair normal
- demeanor=relaxed, benign expression, slow even respirations

- purple-blue striae are Cushing's systdrome
- striae occur with pregnancy + ascites
- cutaneous angiomas (spider nevi) occur with portal HTN liver disease
- veins are more visible with malnutrition
- poor turgor=dehydration
- altered pubic hair patterns occur with hormone abnormality and chronic liver disease
- absolute stillness, resisting any movement occurs with peritonitis

Potential causes of abdominal distention:
- obesity
- air or gas
- ascites
- ovarian cyst
- pregnancy
- feces
- tumor

Ascites is collection of free fluid in peritoneal cavity by increased hydrostatic pressure from portal HTN

Auscultate:
- Diaphragm and press LIGHTLY
- Bowel sounds

- listen in all 4 quads starting in RLQ
- normal = gurgles 5-30 times per minute
- silent abdomen is uncommon must listen for 5 minutes before stating it is absent of sound
- Borborygmus is normal=stomach growling

Abnormal Bowel Sounds
1. Hyperactive
2. Hypoactive

1. sounds are loud, high-pitched, rushing, tinkling sounds signal increased motility
2. absent sounds follow abdominal surgery or with inflammation of the peritoneum

Vascular Sounds (house shape)
- listen for bruits w/bell w/firm pressure

Aorta
Rrenal Lrenal



umbilicus
Riliac Liliac

Rfemoral Lfemoral

Percussion:
- all 4 quadrants
- should predominantly be tympanic (air)
- dullness occurs?
- hyperresonance occurs?

- dullness occurs over a distended bladder, adipose tissue, fluid, or a mass
- hyperresonance is present with gaseous distention

Percuss for liver span
- percuss downward at the right MCL from resonance to dullness, mark area (5-7th ICS)
- percuss upward at the right MCL from tympany to dullness, mark area
- span is usually 6-12 cm
- (males=10.5cm) (females=7cm)

Percussion of Liver using Scratch Test
- place stethoscope over liver
- scratch the abdomen lightly from the RLQ upwards
- when the sound becomes magnified you are at the liver
- what is Hepatomegaly?

- enlarged liver span

SplenicDullness
- percuss for a dull note from the 9th to 11th ICS behind the left midaxillary line MAL
- usually less than 7 cm
- percuss in the lowest interspace in the left anterior axillary line AAL=tympanic
- deep breath=should remain tympanic
- what is splenomegaly?

enlarged spleen occurs when percussion becomes dull from tympany, also mononucleosis, malaria, hepatic cirrhosis

Percuss for CVA costovertebral angle
- indirect fist percussion causes the tissues to vibrate instead of producing a sound
- assess the kidney at 12th rib at the costovertebral angle on lower left back
- place hand over and thump with ulnar edge
- thud should be felt but no pain

Assessing Ascites-Fluid Wave
- patient has bulging flanks, distended abdomen, protruding umbilicus
- differentiate ascites from gaseous distention
1. assess for fluid wave: large amounts of fluids

1. stand on patient's right side (patient supine)
2. place ulnar edge of patients hand firmly on abdomen in the midline
3. place your left hand on person's right flank
4. with right hand, reach across abdomen and give the left flank a firm strike
4. if ascites present, fluid wave will be present and will tap left hand
5. if distention is due to gas or adipose tissue no tap will be present across the abdomen

Assessing Ascites-Shifting Dullness (percussion)
- patient has bulging flanks, distended abdomen, protruding umbilicus
- differentiate ascites from gaseous distention
1. assess for Shifting dullness: > 500mL
2. NOTE it will not detect < 500mL

1. ascites fluid settles by gravity into the flanks, displacing the air-filled bowel upward
2. should hear tympanic over the top of the abdomen due to gas-filled intestines float over the fluid
3. percuss down the side of the abdomen and mark the location as it goes from tympanic to dull
4. roll patient toward you or on right side
5. fluid will gravitate to the dependent side, dispacing the lighter bowel upward
6. percuss the upper side of the abdomen and move downward until you reach dullness and mark this spot
7. this new level should up higher towards umbilicus

Picture of Ascites
**NOTE** Ultrasound is only definitive tool

Palpation is used to judge the size, location, consistency of certain organs and to screen for abnormal mass or tenderness
1. use additional measure to ensure patient comfort and muscle relaxness

1. bend patient's knees
2. keep your palpating hand low and parallel to the abdomen
3. teach patient to breathe slowly (in nose, out mouth)
4. keep your own voice low and soothing, conversate
5. use emotive imagery (scene of a beach on nice day)
6. with ticklish person, keep their hand under your own
7. alternative method is to palpate right after percussing using the stethoscope as a distractionary tool

1. Light palpation
2. Deep palpation

1. palpate lightly using finger pads in all 4 quadrants about 1 cm deep look for with gentle rotary motion do not drag fingers as you move from spot to spot:
2. palpate deeply 5-8 cm deep, to overcome obese/muscular use bimanual technique (top hand pushes, bottom hand palpates)
3. note location, size, consistency and mobility of any palpable organs and presence of any abnormal enlargement, tenderness, or masses
4. voluntary guarding is normal reaction to cold, tense, or ticklish and is bilateral
5. look for involuntary rigidity, it is constant board like hardness of the muscles, may be unilateral and protective mechanism of inflammation of the peritoneum, can be painful when trying to sit up

Organs normally palpated
- Liver
- Spleen
- Kidney
- Aorta

Mild tenderness normally is present when palpating ? Any other tenderness should be investigated.
If mass identified note the following?

1. Sigmoid colon
2. Location, Size, Shape, Consistency (soft, firm, hard), Surface (smooth, nodular), Mobility, Pulsatility, Tenderness

Palpating Liver
1. palpate in RUQ for borders
2. place left hand in back 11th to 12th rib
3. place right hand on RUQ with fingers parallel to midline
4. press deeply down and under right costal margin while patient inhales deeply
5. normal is to feel liver bump fingers as diaphragm pushes it down

Hook Technique for Liver Palpation
- stand up at the person's shoulder, face their feet, hook fingers over the costal margin, during inhalation feel for liver bumping against your fingertips

Palpating Spleen
1. place left hand over patients abdomen and behind left side at 11th and 12th rib, lifting to support
2. place right hand on LUQ with fingers pointing to axilla just below rib margin
3. push down and under the left costal margin while the patient is breathing deeply

If Spleen is enlarged it may be displaced if you suspect this you can?

Roll the person onto his right side to displace the spleen more forward and downward, then proceed with normal palpation technique

Palpate the kidneys
1. right kidney (yes palpable)
2. left kidney (not normally palpable)

1. place hands together in a "ducks bill" in right flank while patient takes a deep breath, press 2 hands together firmly, may feel slight round, smooth, mass
2. reach left hand across abdomen and behind the left flank, push your right hand deep into abdomen while person breathes deeply, should not be palpable

Palpate the Aorta
- use your opposing thumbs and fingers (like pinching) to palpate the aortic puslation and upper abdomen slightly left of midline
- normal is 2.5 to 4 cm wide
- 80% of aneurysms palpable

...

1. enlarged liver
2. enlarged nodular liver
3. enlarged gallbladder
4. enlarged spleen
5. enlarged kidney
6. aortic aneurysm

1. smooth, nontender, occurs with fatty infiltration, portal obstruction or cirrhosis and lymphocytic leukemia
2. nodular occurs with late portal cirrhosis, metastic cancer or tertiary syphilis
3. tender suggests acute cholecystitis, involuntary rigidity, area is painful to fist percussion and inspiratory arrest (Murph's sign) enlarged nontender has stones
4. it enlarges down and midline, acute is soft with round edges and chronic is firm and hard with sharp edges, tenderness is associated with inflammation of peritoneum
5. occurs with hydronephrosis, cyst or neoplasm, has splenic notch, spleen is dull to percussion, kidney is not
6. 95% located below renal arteries, 80% palpable during routine physical examination and feel like pulsating mass in upper abdomen just left of midline, bruit will be heard

Rebound Tenderness (Blumberg's sign)
- press deeply into abdomen, remote from the area of discomfort
- hold hand at 90 degree angle and push slowly, deeply
- rapidly withdraw hand and fingers and assess for sharp stabbing pain, normal=no pain

Murphy's Sign (inspiratory arrest)
- hold fingers perpendicular under liver border
- ask person to take a deep breath
- normal=no pain during inspiration

...

Test for Appendicities
1. iliopsoas muscle test (w/acute appendicitis)
2. obturator test (ruptured appendix, pelvic abscess)

1. with person supine, examiner lifts right leg straight up, flexing at hip, then push down over thigh as patient tries to resist and hold leg up, normal=no pain
2. with patient supine, lift right leg, flexing at hip and 90 degree angle at knee, hold ankle and rotate leg internally and externally (sitting indian style) normal=no pain

Abdominal Reflexes
- patient in supine position with knees slightly bent
- use handle end of reflex hammer, wood applicator tip, to stroke the skin from side of abdomen to midline
- test at upper and lower abdominal levels
- normal=ipsilateral contraction of the abdominal muscle
- normal=superficial reflex is present
1. ABSENT OF SUPERFICIAL REFLEXT

1. occurs with diseases of pryamidal tract and contralateral side with stroke

Cecum

first part of large intestine

Cholecystitis

inflammation of gallbladder

Hernia

abnormal protrusion of bowel through weakening in abdominal musculature

Paralytic ileus

complete absence of peristaltic movement following abdominal surgery or complete bowl obstruction

Peritoneal friction rub

rough grating sound heard through the stethoscope over the site of peritoneal inflammation

Sequence of techniques during exam of abdomen

1. inspection
2. auscultation
3. percussion
4. palpation

What is noted during inspection of abdomen?

venous pattern, peristatic waves, and contour

Right upper quadrant tenderness may indicate pathology in the?

liver, pancreas, or ascending colon

Hyperactive bowl sounds are?

high-pitched, rushing, and tinkling

The absence of bowel sounds is established after listening for?

5 minutes

Range of normal liver span in right midclavicular line in adult is?

6-12 cm

Striae when older are?
Striae when recent are?

older are silvery white
pink or blue, then turn silver white

Dull percussion note forward of the left midaxillary line is?

indicative of splenic enlargement

Tenderness during abdominal palpation is expected when palpating?

sigmoid colon

Murphy's sign is best described as?

pain felt when taking a deep breath when examiner's fingers are on the approximate junction of organ being tested

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