N201 - Abdominal Assessment

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Systems included in the Abdominal Region

GI
Reproductive (female)
Lymphatic
Urinary

Borders of Abdominal Region

superiorly by costal margins
inferiorly by symphysis pubis and inguinal canals
laterally by the flanks

Landmarks of 4 Quadrants

Midline: from tip of sternum (Xiphoid Process) through umbilicus to symphysis pubis
Across: at umbilicus

Midline regions of "9 Regions" landmark division of Abdomen

Top: Epigastric
Middle: Umbilical
Bottom: Hypogastric/ Suprapubic

Structures in RUQ

Ascending and transverse colon
Duodenum
Gallbladder
Hepatic flexure of Colon
Liver
Pancreas (head)
Pylorus (the small bowel- or ileum- traverses all quadrants)
Right adrenal gland
Right kidney (upper pole)
Right ureter

Structures in LUQ

Left adrenal gland
Left kidney (upper pole)
Left ureter
Pancreas (body and tail)
Spleen
Splenic flexture of colon
Stomach
Transverse decending colon

Structures in RLQ

Appendix
Ascending colon
Cecum
Right kidney (lower pole)
Right ovary and tube
Right ureter
Right spermatic cord

Structures in LLQ

Left kidney (lower pole)
Left ovary and tube
Left ureter
Left spermatic cord
Descending and sigmoid colon

Midline Structures within abdomen

Bladder
Uterus
Prostate gland

Peritoneum

thin shiny, serous membrane; lines the abdominal cavity, providing a protective covering for most of the internal abdominal organs.

solid viscera

Organs that maintain their shape:
liver, pancreas, spleen, adrenal glands, kidneys, ovaries, uterus

Hollow viscera

Organs that change shape depending on their contents:
stomach, gallbladder, small intestine, colon, bladder

Structure and Function of the Gallbladder

muscular sac concentrates and stores bile (needed for to digest fats). Located posterior of liver normally not palpated.

Location and Pain Radiation of Pancreas

Located behind stomach, pain can refer to back

Structure and Function of Spleen

7 cm wide, above L kidney below diaphragm, normally not palpable. Functions normally to filter blood of cellular debris, digest microorganisms and return the breakdown products to the liver.

Splenomegaly

spleen can be enlarged and therefore palpable

Structure and Function of Liver

largest solid organ in body, located below diaphragm, has 4 lobes, fills most of RUQ, and extends to left MCL. Detoxifies drugs and alcohol converts glucose to glycogen and stores vitamins.

Structure and Function of Pancreas

located mostly behind stomach deep in upper abdomen, normally not palpable. It is an endocrine gland and accessory organ of digestion. Produces insulin and glucagon, pancreatic enzymes

Structure and Function of Kidney

filtration, elimination of metabolic waste products, also role in BP control and maintenance of water, Na & electrolyte balance. located high & deep under diaphragm, considered posterior organs ~ T12, L3 vertebrae. Assess tenderness at CVA angle. Right kidney is slightly lower b/c of position of liver.

Structure and Function of Stomach

distensible, flask like organ, not palpable usually, stores, churns and digests food.

Structure and Function of Small Intestines

largest part of digestive tract, aids in digestion and absorption of nutrients via mucosal projections lining its walls, coiled in all 4 quadrants.

Structure and Function of Colon

secretes large amounts of alkaline mucus to lubricate intestine, neutralizes acids from intestinal bacteria. Water is absorbed, leaving waste products to be eliminated.

Visceral Pain

Hollow organs distended described as dull aching burning cramping colicky

Parietal Pain

When the parietal peritoneum becomes inflamed localizes to the source and is severe and steady

Referred Pain

Distant sites pain tracels or refers from the primary site and becomes highly localized at the distant site.

Dyspepsia

upset stomach

dull, aching pain

appendicitis, acute hepatitis, biliary colic, cholecystitis

Burning, gnawing pain

GERD, colitis, appendicitis

Colicky (crampy) pain

colon cancer

Sharp, knifelike pain

splenic abscess rupture, renal colic, renal tumor

Variable pain

stomach cancer

Pressure pain

BPH, urinary retention

Ask client to __________ before exam.

urinate

Position of Client during exam

comfortable supine position with knees flexed over a pillow or position client so that the arms are either folded across chest or at sides to ensure abdominal relaxation

Stand to __________ side of client for exam.

right

When do you assess tender areas?

last.

Order of Assessment

Inspection
Auscultation
Percussion
Palpation

Why does Auscultation come before Percussion and Palpation?

because palpation and percussion can alter bowel sounds

Skin Inspection

* COLOR of the skin: may be paler than the general skin tone because this skin is seldom exposed
* VASCULARITY of skin: scattered fine veins may be visible. Dilated superficial capillaries without a pattern may be seen in older clients.
* STRIAE: old, silvery, white stretch marks from past pregnancies or weight gain.
* SCARS: pale, smooth, minimally raised old scars may be seen. Measure length with cm ruler; document location by quadrant and reference lines.

Abdominal Shapes from Side

* Normal: Flat, rounded
* Abnormal Scaphoid protuberant
* Abdominal distention- caused by obesity, air or gas, pregnancy fibroids, full bladder, tumor (another common cause of abd distention = feces, fluid)

Purple discoloration of flanks (Grey Turner sign)

indicates bleeding within the abdominal wall possibly from trauma

Yellow hue

jaundice

Pale taut skin with acites (abd swelling indicating fluid accumulation in abd cavity)

usually results from liver failure or liver disease.

Redness

inflammation

Dilated veins

cirrohosis of the liver, inferior vena cava obstruction, portal hypertension

Blue pink straie

Cushing Syndrome

Inspection of Contour, Symmetry, & Movement

* Assess abdominal symmetry.
* Have client raise head to further assess the abdomen for herniation or to differentiate a mass within abdominal wall from one below it. Abdomen should not bulge.
* Inspect abdominal movement when client breathes: abdominal respiratory movements may be seen.
* Observe aortic pulsations: a slight pulsation may be visible in the epigastrium and extends full length in thin people.
*Watch for peristaltic waves: normally not seen, although may be seen in very thin people as slight ripples.

Caput Medusae

Engorged superficial capillaries of abdomen

Cullen's Sign

Bluish or purple discoloration around umbilicus: intrabdominal bleeding

Deviation of umbilicus

may be caused by pressure from mass, enlarged organs, hernia, fluid or scar tissue

Inspection of aortic pulsation

slight pulsation visible in epigastrium, may be noted in thin people. Wide, exaggerated pulsations can be seen with abd aortic aneurysm.

Inspection of peristaltic waves

may be seen in very thin people

Hernia

protrusion of bowel through a weakness in abd wall. More prominent when head is raised

Protuberant Abdomen

distended abdomen may be due to obesity air gas or fluid. Distention below the umbilicus may be due to a full bladder.

Scaphoid abdomen

may be seen with severe weight loss or cachexia, starvation or terminal illness

Order of Quadrant Auscultation

RLQ, RUQ, LUQ, LLQ

Listen for at least __________ in an abdominal quadrant before concluding that bowel sounds are absent.

5 minutes

Normal Rate of Bowel Sounds

5 to 30/sec

Hyperactive Bowel Sounds

loud, prolonged gurgles characteristic of stomach growling (borborygmi), can be due to diarrhea, gastroenteritis, or early bowel obstruction

Hypoactive Bowel Sounds

indicate decreased motility of bowels, can be due to abdominal surgery or bowel obstruction

Borborygmi

loud hyperactive sounds, stomach growling

Where are bowel sounds more active?

over the ileocecal valve in the RLQ

Normal Bowel Sounds

high pitched, gurgling and irregular, occur ever 5 to 15 seconds

Absent Bowel Sounds

may be associated with peritonitis or paralytic ileus

Increasing pitch of bowel sounds

most diagnostic of obstruction because it signifies distention

Auscultation for Vascular Sounds

Place bell of stethoscope over abdominal aorta and renal, iliac, and femoral arteries to listen for bruits (normally not heard)

Presence of bruit indicates..

aneurysm or arterial stenosis

Auscultation for Venous Hum

vibration sound heard with bell of stethoscope in the epigastric and umbilical areas (normally not heard)

Bruit

sound made when blood flow in an artery is turbulent or obstructed

Ausculatating for vascular sounds is especially important for who?

A client who has hypertension or if you suspect arterial insufficiency of the legs

Friction Rubs

abnormal, high-pitched, rough, grating sounds produced when the large surface area of the liver or spleen rubs the peritoneum. Heard in association with respiration. Indicate inflammation or tumors. Rare however one heard in the epigastric or umbilical areas indicates increased collateral circulation between portal and venous systems especially in cirrhosis of the liver

Auscultation for friction rub

over liver and spleen by listening over the right and left lower rib cage with the diaphragm of stethoscope.

Order & Pattern of Percussion

RLQ, RUQ, LUQ, LLQ / must percuss in a few spots in each quadrant

Sound heard the most in percussion of abdomen

tympany

Percussion of Liver

Mark upper and lower border. Begin at RLQ at MCL and percuss upward until dullness is heard. Mark this. Patient takes deep breath, percuss over Right chest down MCL until dullness is heard. Mark this. Measure span of Liver.

Normal span of liver

Normal: 6 to 12 cm (Men > Women); Mean span for men=10.5 cm and women=7.0 cm.

What could be the reason for not being able to find the lower border of the liver during percussion?

lower border may be obscured by intestinal gas

Location of upper border of Liver

between the fifth and 7th intercostal spaces

Hepatomegaly

Enlarged liver. Characteristic of liver tumors, cirrhosis, abscess and vascular engorgement

When is a Liver considered enlarged?

When the span of the liver is 1-3 cm below costal margin, it is considered enlarged (unless pressed down by the diaphragm)

When is the Scratch Test performed?

When liver borders cannot accurately be percussed

Scratch Test

Auscultate over liver and starting in RLQ, scratch lightly over the abdomen, progressing upward toward the liver. Scratch using short strokes every 1 to 2 cm toward the stethoscope.
The sound produced by scratching becomes more intense over liver.

Percussion of Spleen

Percuss lowest interspace in left anterior axillary line. This area is usually tympanitic.
Ask client to take a deep breath. When spleen size is normal, percussion note usually remains tympanitic. If it changes to dull on inspiration, it is suggestive of splenic enlargement.

Splenic enlargement can be from..

trauma, portal hypertension, and mono

Percussion Location of Stomach

LUQ at left lower anterior rib cage and left epigastric region

Normal Sounds of Stomach when Percussing

low-pitched sound of tympany. Sound is influenced by contents of stomach. A very loud sound and an increased area suggests gastric dilation. Dull percussion sound indicates a mass of the stomach

Percussion of Kidneys

Use blunt percussion to assess for tenderness in difficult-to-palpate structures.
Position client in sitting position with back to examiner.
Place left hand flat against costovertebral angle (CVA) over the twelfth rib. Use ulnar side of right fist to strike left hand.

Normal findings of Kidney Percussion

no tenderness is elicited. The examiner may sense only a dull thud.

Pain or tenderness over CVA may suggest..

kidney infection or renal calculi (stones)

When to NOT percuss over CVA

if client complains of pain, discomfort, tenderness, oliguria or hematuria.

How can you prevent muscle guarding when palpating the abdomen?

make sure your hands are warm

When to palpate areas of tenderness

last

Order of Pressure when palpating abdomen

Begin with general pressure and gradually increase it.

What should you do if the client is ticklish?

have client perform self-palpation with your hand over client's hand. Gradually remove the client's hand when ticklishness is gone.

How do you assess for patient's pain or discomfort during palpation?

Observe client's face for changes in expression

What is light palpation used for?

to identify areas of tenderness and muscular resistance

Involuntary reflex guarding

is serious and reflects peritoneal irritation. With guarding the abdomen is rigid and the rectus muscle fails to relax with palpation on exhalation. Can include all or part of abd, but is usually seen on the side b/c of nerve track patterns. Right sided guarding for example may be due to cholecystitis.

Procedure of Light Palpation

With hands and forearm on a horizontal plane, use the pads of the approximated fingers to depress the abdominal wall 1 cm. Avoid short, quick jabs. Lightly palpate all four quadrants in a systematic manner by gently lifting fingers and moving to next area.

Normal findings of light abdominal palpation

no guarding; abdomen is soft

Purpose of Deep Palpation

to assess for organ enlargement, masses, bulges, or swelling

Procedure of Deep Palpation

Use palmar surface of fingers, compress to a maximum depth of 5 to 6 cm in RLQ. Perform bimanual palpation if resistance is encountered, client is obese, or to assess deeper structures. Identify any masses and note location, size, shape, consistency, tenderness, pulsation, and degree of mobility. Continue palpation of other quadrants.

Normal findings of deep abdominal palpation

only aorta and edge of liver are palpable. No palpable organ enlargement, nor masses, bulges, or swelling.

Palpate the umbilicus and surrounding area for...

swellings, bulges, or masses.

How to palpate the aorta

Use thumb and first finger or use two hands and palpate deeply in the epigastrium, slightly to the left of midline.

Normal findings of aortic palpation

aorta is approximately 2.5 to 3.0 cm wide with a moderately strong and regular pulse. Possibly, mild tenderness may be elicited.

Indication of Abdominal Aortic Aneurysm

Wide, bounding pulse

Purpose of palpating the Liver

to note consistency and tenderness

Bimanual Method of Liver Palpation

stand at client's right side and place left hand under client's back at the level of 11th to 12th ribs. Lay right hand parallel to right costal margin (fingertips should point toward client's head). Ask client to inhale, then compress upward and inward with your fingers.

Hooking Method of Liver Palpation

stand to right of client's chest. Curl (hook) fingers of both hands over edge of right costal margin. Ask client to take deep breath, and gently, but firmly, pull inward and upward with fingers.

What can a hard, firm liver indicate?

cancer, late cirrhosis, or syphilis

What can a tender liver indicate?

vascular engorgement, hepatitis, or abscess

Normal findings of liver palpation

liver is usually not palpable, although it may be felt in some thin clients. If lower edge is felt, it should be firm, smooth, and even. Mild tenderness may be normal

What can nodularity in liver indicate?

may occur with tumors, cancer, late cirrhosis, or syphilis.

Procedure of Spleen Palpation

Stand at client's right side, reach over abdomen with left arm and place hand under posterior lower ribs. Pull up gently. Place right hand below left costal margin with fingers pointing towards client's head. Ask client to inhale, and press inward and upward as support is provided with other hand.

Normal findings of Spleen Palpation

spleen is seldom palpable at left costal margin; rarely, the tip is palpable in the presence of a low, flat diaphragm as in emphysema.

How can you tell if the spleen is enlarged?

It will be palpable.

How large is the spleen when palpable?

at least 3 times its normal size

Hand placement for palpation of kidney

Support right posterior flank with left hand, and place right hand in RUQ just below the costal margin at the MCL.

Procedure to capture the kidney

Aask client to inhale. Then, compress fingers deeply during peak inspiration. Ask client to exhale and hold breath briefly. Gradually release pressure of right hand. If kidney has been captured, it can be felt slipping beneath fingers. To palpate left kidney, reverse procedure.

Normal findings on Kidney Palpation

kidneys not palpable. Sometimes, lower pole of right kidney may be palpable because of its lower position. If palpated, it should feel firm, smooth, and rounded. May or may not be slightly tender.

What can an enlarged kidney be due to?

a cyst, tumor, or hydronephrosis

Purpose of Palpation of Urinary Bladder

to palpate for a distended bladder

Procedure of Urinary Bladder Palpation

Using deep palpation, begin at symphysis pubis, and move upward and outward to estimate bladder borders.

Normal findings on bladder palpation

empty bladder not palpable

Abnormal Bladder palpation findings

* Distended bladder is palpated as a smooth, round, and somewhat firm mass.
* Moderately full bladder is palpable above symphysis pubis.
* Full bladder is palpated above symphysis pubis and may be close to umbilicus.

Another way (besides palpation) to check for bladder distention

dull percussion tones

Procedure of Inguinal Lymph Node Palpation

Place client in supine position, with knees slightly flexed. Using finger pads of 2nd, 3rd, & 4th fingers, apply firm pressure and palpate with a rotary motion in the right inguinal area. Palpate for lymph nodes in left inguinal area.

Normal findings on Inguinal Lymph Node Palpation

palpation of small, movable, nontender nodes less than 1 cm in diameter.

Abnormal findings on Inguinal Lymph Node Palpation

lymph nodes greater than 1 cm in diameter or elicitation of nonmovable, tender lymph nodes. Can indicate localized or systemic infections, cancer or lymphomas

Procedure for Testing for Shifting Dullness for Ascites

Client is supine. Percuss flanks from the bed upward toward umbilicus. Note change from dullness to tympany and mark this point.
Turn client onto side. Percuss abdomen from bed upward. Mark level where dullness changes to tympany.

Normal findings when testing for Shifting Dullness

no change from tympany to dullness

Abnormal findings when testing for Shifting Dullness

marked change from tympany to dullness as examiner percusses outward and downward. This change takes place above the prior-marked fluid line. Indicates ascites is present. Ascitic fluid sinks with gravity.

visual indication of ascites

distended abdomen or bulging flanks

Procedure for Fluid Wave Test for Ascites

Client is supine. Need assistance with this test. Ask client or assistant to place ulnar side of hand and lateral side of forearm firmly along midline of abdomen. Firmly place the palmar surface of fingers and hand against one side of client's abdomen. Use other hand to tap opposite side of abdominal wall.

Normal findings for Fluid Wave Test

no fluid wave is transmitted

Abnormal findings for Fluid Wave Test

movement of a fluid wave against the resting hand suggests large amounts of fluid are present (ascites).

Purpose of Ballottement Technique for Masses

palpation technique performed to identify a mass or enlarged organ within an ascitic abdomen by displacint excess fluid

Single-Hand Method of Ballottement Technique for Masses

using a tapping or bounding motion of the finger pads over the abdominal wall, feel for a floating mass.

Bimanual Method of Ballottement Technique for Masses

place one hand under the flank (receiving/feeling hand), and push the anterior abdominal wall with the other hand

Normal findings of Ballottement Technique for Masses

no palpable mass

Abnormal findings of Ballottement Technique for Masses

in client with ascites, a freely movable mass moving upward (floating), can be felt. It is felt at fingertips and can be palpated for size

Procedure of Test for Rebound Tenderness

Client is supine. Apply several seconds of firm pressure to the abdomen, with hand at a 90o angle (perpendicular to abdomen) and the fingers extended. Quickly release the pressure.

Normal findings of Test for Rebound Tenderness

pain is not elicited

Abnormal findings of Test for Rebound Tenderness

as abdominal wall returns to its normal position, client complains of pain at pressure site (direct rebound tenderness) or at another site (referred rebound tenderness). [pain is felt on release of hand] May indicate peritoneal irritation--> sharp pain in area of inflammation.

On whom do you measure abdominal girth?

all clients with abdominal distention

What time do you measure abdominal girth?

at same time each day. Ideally in morning just after voiding.

Ideal positioning for measuring abdominal girth

standing; otherwise client should be in supine position. Head may be slightly elevated for orthopneic clients. Client should be in same position for all measurements.

Procedure for measuring abdominal girth

* Use a disposable or easily cleaned tape measure.
* Place tape measure behind client and measure at umbilicus.
* Record measurement in inches or centimeters.
* Take all future measurements as same location. Mark site with a ballpoint pen.

What happens to abdominal musculature in elderly?

diminishes in mass and loses much of its tone

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