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
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.
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.
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.
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.
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
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
Pale taut skin with acites (abd swelling indicating fluid accumulation in abd cavity)
usually results from liver failure or liver disease.
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.
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.
Protuberant Abdomen
distended abdomen may be due to obesity air gas or fluid. Distention below the umbilicus may be due to a full bladder.
Listen for at least __________ in an abdominal quadrant before concluding that bowel sounds are absent.
5 minutes
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
Auscultation for Vascular Sounds
Place bell of stethoscope over abdominal aorta and renal, iliac, and femoral arteries to listen for bruits (normally not heard)
Auscultation for Venous Hum
vibration sound heard with bell of stethoscope in the epigastric and umbilical areas (normally not heard)
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.
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.
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
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)
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.
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.
When to NOT percuss over CVA
if client complains of pain, discomfort, tenderness, oliguria or hematuria.
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
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.
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.
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.
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.
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
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.
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.
Procedure of Urinary Bladder Palpation
Using deep palpation, begin at symphysis pubis, and move upward and outward to estimate bladder borders.
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.
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.
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.
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.
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
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.
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.
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 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
There are increased complaints of what in the elderly?
gas or epigastric discomfort along with constipation
What are the 4 symptoms of alcoholism?
* Craving
* Loss of Control
* Physical Dependence
* Tolerance
What is a safe level of drinking alcohol?
Up to 2 drinks/day for men and 1 drink/day for women and older people.