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surface landmarks

1. borders of abdominal cavity
2. abdominal muscles

internal anatomy: hollow

1. stomach
2. GB
3. small intestine
4. colon
5. bladder

Internal anatomy: solid

• Liver
• Pancreas
• Spleen
• Adrenal glands • Kidneys
• Ovaries
• Uterus

health history questions: subjective

• Appetite: unintended gain/loss, what time frame
• Dysphagia: difficulty swallowing
• Food intolerance
• Abdominal pain
• Nausea/vomiting: does it wake you at night
• Bowel habits: iron pills-->constipation-->stool softener
• Abdominal history
• Medications
• Nutrition

GI: routine techniques (general steps) - 6

• Observe (general behavior & position/posture)
• Inspect for skin color, surface characteristics, contour, surface movement
• Auscultate (BS & vascular sounds)
• Palpate (light then deep)
• Percuss CVA prn
• Special techniques prn (rebound tenderness, McBurney's, iliopsoas, obturator)

When inspecting the abdomen what are we observing?

• Contour
• Symmetry
• Umbilicus
• Skin
• Pulsation or surface movement
• Hair distribution
• sit up and cough (look for bulges)

contours: 4

1. flat
2. Scaphoid (concave)
3. rounded
4. protuberant (looks pregnant)

special inspection

ostomy

Auscultate

• Bowel sounds should be heard (no bowel sounds often due to anesthesia)
• Vascular sounds (bruits) should not hear @ ARIF= aorta, renal, iliac, femoral

What do we auscultate the stomach for & what does it sound like?

Bowel sounds which are high pitched gurgles or clicks.

What is a Bruit?

vascular = swishing sounds.
- would hear is artery is narrow (plaque). swishing is not constant. ex. swish-pause-swish
- A vascular sound caused by turbulent blood flow. It sounds like swishing & occur during systole. They are continuous regardless of the patients position.

What does a Bruit over the aorta indicate?

Aneurysm

percuss (steps) * test question

• General tympany - due to air w/in the bowels
• Liver span
- Usual technique
- Scratch test
• Splenic dullness (normally not percussed)
• Costovertebral angle tenderness
• Bladder
• Special procedures
- Fluid wave
- Shifting dullness

percuss: tones * test question

1. percuss (indirect) all quadrants
- develop routine to ensure all areas covered
- percuss for tympany & dullness
2. Tympany = most common tone due to presence of gas
- suprapubic area → dull when bladder is distended

tympany

low-pitched note heard on percussion of a hollow organ such as the stomach

percuss: liver

-Right midclavicular line
• Below umbilicus, percuss upward (tympany to dullness)
• Over lung, percuss downward (resonance to dullness)
• Distance between two lines = liver span (2.5 inches/6‐12 cm)

Steps for palpation

• Palpate abdomen (light) (1‐2cm) for tenderness, muscle tone, and surface characteristics
• Palpate abdomen (deep) (4‐6cm) for tenderness, masses, and aortic pulsation (probably never do this)

Liver palpation

- not routine

Reasons for enlarged liver

cirrhosis, cancer, hepatitis, fatty liver

McBurney's sign

• test for appendicitis
- aka rebound tenderness (Blumberg sign), pain when pressure lifted
- Absence of pain when performed is a negative test

What is Ballottement?

A palpation technique to determine a floating mass in the abdomen with 1 or 2 hands.
- Usually performed on a fetus

What is Murphy's Sign?

A test used if Cholecystitis (inflamed GB) is suspected. The patient is asked to take a deep breath . The nurse begins palpating the gallbladder & the patient experiences pain & stops inhaling.
- aka Inspiratory breath

What is the Rebound tenderness test used for?

Abdominal pain that is suspect to inflammation. More pain is experienced when pressure of the abdomen is released instead of applied. An indication of peritoneal infection

What is the Iliopsoas Muscle test?

- This test is performed if acute appendicitis is suspected no pain when performed is a negative test
- Hand on right thigh, patient attempts to raise right leg while you press down. Pain = appendicitis

What is a Obturator Muscle test?

- This test is performed if a ruptured appendicitis, or a pelvic abscess is suspect. No pain is a negative test
- Patient bends knee, you hold knee and ankle & rotate leg medially & laterally. Pain = ruptured appendix/pelvic abscess.

To hear vascular sounds of the abdomen what part of the Stethoscope is used?

The bell

Where might a Venus hum be found on the abdomen?

The Epigastric region or the Umbilicus region. They are very rare & sound like a continuous soft low pitched hum

What might be the cause of a venous hum?

Portal Hypertension or Cirrhosis

When palpating the stomach if ridgity is felt what could it indicate?

Peritoneal irritation

What type of palpitation is performed on the abdomen to assess tenderness, masses, aortic pulsations, or organ size?

Deep & bimanual

Where can we palpate to find aortic pulsations?

The epigastric region

What do we palpate the liver for?

Tenderness & descent (location)

Can the gallbladder be palpated?

Not a healthy one

What are abnormal findings when palpating the gallbladder?

The first being that it is palpable (Cholecystitis), tender (infection or trauma).

What does a palpable spleen feel like?

A firm mass that will bump against the nurses fingers during palpation

What are the kidneys palpated for?

Contour, presence, & tenderness (indication of trauma or infection)

What is CVA? Costovertebral angle?

An indirect method of percussion of the kidneys

What can CVA tenderness or pain indicate?

1. infection around the kidney = perinephric disease
2. kidney inflammation = pyelonephritis
3. renal stone
* VS should be checked for fever and ↑ HR. Nausea can be an additional sign of kidney inflammation

What sounds are the most common when Percussion is used on the Abdomen?

Tympany is the most common caused by gas

When percusing the suprapubic area why might we hear a dullness sound?

The bladder is full

What are abnormal abdominal sounds?

Dullness in a localized area can indicate an abdominal mass

What do we percuss the liver to determine?

Size & descent(location)

What is a normal finding when percussion of the liver is performed?

The midclavicular liver span is 2.5 - 4.5 cm .

What is an abnormal finding when percussion of the liver is performed?

When the lower border of the liver is 2-3 cm below the costal margin (indication of Hepatomegaly)

Can you hear any noises when percussing the Spleen?

Not normally, If dullness is heard it usually indicates Spleen enlargement (injury or mono)

What is a Shifting Dullness test?

A test for determining fluid in the abdomen. Movement of dullness as the client shifts positions indicates fluid in the peritoneal cavity

What is a Fluid Wave test?

A test for determining fluid ascites of the abdomen. You will be able to feel the fluid wave as you tap.

dysphagia

difficulty swallowing
Ex. Alzheimers, sometimes add thickener, makes it easier to swallow

peritoneal friction rub

a lot of fluid

Abnormal findings: Abdominal distention

• Obesity
• Air or gas
• Ascites
• Ovarian cyst • Pregnancy
• Feces
• Tumor

Abnormalities on inspection (2)

1. Umbilical hernia
2. incisional hernia

Abnormal bowel sounds

• Hypoactive bowel sounds
• Hyperactive bowel sounds
• No true normal levels

Variations Digestion: Older adults

1. Changes in digestion/absorption of nutrients from alterations in cardiovascular/neurologic systems, but not GI system
2. ↓ mobility or ↓H20 intake, side effects of meds

Variations Esophagus & Gastric: Older adults

-Esophagus (decreased motility/pressure)—increased regurgitation
-Gastric mucosa (degenerates)—decrease gastric acids, digestive enzymes, and motility
• Also, reduction in parietal cells secrete intrinsic factor (vitamin B12 absorption)

Variations Liver: Older adults

- decreased size →reduced storage capacity/protein synthesis
• ↓ cardiac output → ↓blood flow
• metabolism of drugs, hormones & alcohol is less efficient
• deal with medications differently

Variations Intestines: Older adults

- Small intestine (muscles/mucosal surfaces atrophy, villi thin, epithelial cells decrease)— decreased absorption in fats/vitamin B12
• Decreased lipase production—intolerance of fatty foods
- Large intestine (weakened muscle/decreased peristalsis)— constipation
• Bacterial flora [less biologically active]—food intolerance and impaired digestion

Health history: older adults

-Had abdominal pains not felt before
recently?
-Constipation? How defined? Liquids drunk/day? Bulk or fiber eaten? Taking laxatives? How often?
-Do you unintentionally leak urine? When? What do you do to stay dry?

Variations in Exams: Older adults

- Increased fat deposits over abdomen/less
subcutaneous fat over extremities
- Abdomen soft (loss of abdominal muscle tone)—organ palpation easier
- Note distention/concavity associated with general wasting signs or anteroposterior rib expansion

These 2 sound patterns heard through auscultation of the abdomen are Soft, or medium to low pitched mummurs. If they are heard over; the upper midline, or toward the flank, & Epigastric bruits that radiate laterally are indicators of what?

Renal Arterial Stenosis.

What can mimic the dullness of spleen enlargement?

A full stomach or feces in the transverse or descending colon

What else can indicate Splenomegaly?

During inspiration tympany in the stomach will turn to dullness as the enlarged spleen is moved forward.

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