Systems included in the Abdominal Region
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
Bottom: Hypogastric/ Suprapubic
Structures in RUQ
Ascending and transverse colon
Hepatic flexure of Colon
Pylorus (the small bowel- or ileum- traverses all quadrants)
Right adrenal gland
Right kidney (upper pole)
Structures in LUQ
Left adrenal gland
Left kidney (upper pole)
Pancreas (body and tail)
Splenic flexture of colon
Transverse decending colon
Structures in RLQ
Right kidney (lower pole)
Right ovary and tube
Right spermatic cord
Structures in LLQ
Left kidney (lower pole)
Left ovary and tube
Left spermatic cord
Descending and sigmoid colon
Midline Structures within abdomen
thin shiny, serous membrane; lines the abdominal cavity, providing a protective covering for most of the internal abdominal organs.
Organs that maintain their shape:
liver, pancreas, spleen, adrenal glands, kidneys, ovaries, uterus
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.
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.
Hollow organs distended described as dull aching burning cramping colicky
When the parietal peritoneum becomes inflamed localizes to the source and is severe and steady
Distant sites pain tracels or refers from the primary site and becomes highly localized at the distant site.
dull, aching pain
appendicitis, acute hepatitis, biliary colic, cholecystitis
Burning, gnawing pain
GERD, colitis, appendicitis
Colicky (crampy) pain
Sharp, knifelike pain
splenic abscess rupture, renal colic, renal tumor
BPH, urinary retention
Ask client to __________ before exam.
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.
When do you assess tender areas?
Order of Assessment
Why does Auscultation come before Percussion and Palpation?
because palpation and percussion can alter bowel sounds
* 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
Pale taut skin with acites (abd swelling indicating fluid accumulation in abd cavity)
usually results from liver failure or liver disease.
cirrohosis of the liver, inferior vena cava obstruction, portal hypertension
Blue pink straie
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.
Engorged superficial capillaries of abdomen
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
protrusion of bowel through a weakness in abd wall. More prominent when head is raised
distended abdomen may be due to obesity air gas or fluid. Distention below the umbilicus may be due to a full bladder.
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.
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
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)
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
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
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
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
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
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
What happens to the abdominal fat in the elderly?
increased fat deposition
What happens to the mucosal lining of the gastrointestinal tract in the elderly?
becomes less elastic, and changes in gastric motility result in alterations in digestion and absorption
What happens to gastric acid secretion in the elderly?
There are increased complaints of what in the elderly?
gas or epigastric discomfort along with constipation
What is there an increased incidence of in the elderly?
In the elderly, Intestines are subject to ischemia due to __________.
What are the 4 symptoms of alcoholism?
* Loss of Control
* Physical Dependence
What is a safe level of drinking alcohol?
Up to 2 drinks/day for men and 1 drink/day for women and older people.
One drink equals:
* 12-ounce bottle of beer or wine cooler
* One 5-ounce glass of wine
* 1.5 ounces of 80-proof distilled spirits