Abdomen Assessment D. Tanner, RN, MSN NUR 211 Fall Semester.

Abdomen AssessmentAbdomen Assessment

D. Tanner, RN, MSND. Tanner, RN, MSN

NUR 211NUR 211

Fall Semester Fall Semester

Anatomy of the AbdomenAnatomy of the Abdomen

4 Quadrants RUQ, RLQ, LUQ, 4 Quadrants RUQ, RLQ, LUQ, LLQLLQ

MidlineMidline

9 Regions- epigastric, 9 Regions- epigastric, umbilical, suprapubicumbilical, suprapubic

The word "abdomen" has a The word "abdomen" has a curious story behind it. It curious story behind it. It comes from the Latin comes from the Latin "abdodere", to hide. The idea "abdodere", to hide. The idea was that whatever was eaten was that whatever was eaten was hidden in the abdomen.was hidden in the abdomen.

4 Quadrants4 Quadrants

9 Regions9 Regions

Location! Location! Location! Location! Location!Location!

RUQRUQ

liverliver

gallbladdergallbladder

duodenum (small duodenum (small intestine)intestine)

pancreas headpancreas head

right kidney and right kidney and adrenaladrenal

Location! Location! Location! Location! Location!Location!

RLQRLQ

cecumcecum

appendixappendix

right ovary and right ovary and tubetube

Location! Location! Location! Location! Location!Location!

LLQLLQ

sigmoid colonsigmoid colonleft ovary and tubeleft ovary and tube

LUQLUQ

stomachstomachspleenspleenpancreaspancreasleft kidney and adrenalleft kidney and adrenal

GI Variations Due to AgeGI Variations Due to Age

Aging- should not affect Aging- should not affect GI function unless GI function unless associated with a associated with a disease processdisease process

Decreased: salivation, Decreased: salivation, sense of taste, gastric sense of taste, gastric acid secretion, acid secretion, esophageal emptying, esophageal emptying, liver size, bacterial floraliver size, bacterial flora

Increased: constipation!Increased: constipation!

GI Variations with GI Variations with pregnancypregnancy

Decrease in gastric Decrease in gastric motilitymotility

High incidence of N, V (r/t High incidence of N, V (r/t pregnancy hormones) pregnancy hormones) and “heartburn” or acid and “heartburn” or acid refluxreflux

Bowel sounds diminished Bowel sounds diminished r/t enlarged uterus r/t enlarged uterus displacing intestinesdisplacing intestines

Linea nigra- increased Linea nigra- increased pigmentation of abd pigmentation of abd midlinemidline

Striae GravidarumStriae Gravidarum

Nursing History - AbdomenNursing History - Abdomen

Subjective DataSubjective Data: : Ask about:Ask about:AppetiteAppetiteWt gain or lossWt gain or lossDysphagiaDysphagiaIntolerance to certain Intolerance to certain foodsfoodsAny Abdominal Pain of Any Abdominal Pain of Nausea and VomitingNausea and VomitingBowel movementsBowel movementsAny past abdominal Any past abdominal problemsproblems

Nursing HistoryNursing History

Infants and Children – Infants and Children – Ask: bottle or breast fed, any table Ask: bottle or breast fed, any table

foods, how often & how well & how foods, how often & how well & how much the baby eat, any problems with much the baby eat, any problems with constipation, c/o of any abdominal painconstipation, c/o of any abdominal pain

Teenagers-Teenagers- Ask: nutritional assessment, activity & Ask: nutritional assessment, activity &

exercise patterns, recent wt. loss or gain exercise patterns, recent wt. loss or gain

Nursing HistoryNursing History

Older AdultsOlder Adults Ask: how do you get your groceries?Ask: how do you get your groceries?

prepare your meals? prepare your meals? do you have any trouble swallowing?do you have any trouble swallowing?

how often do your bowels move?how often do your bowels move?how often do you take anything for how often do you take anything for constipation? Rx / OTC/ herbsconstipation? Rx / OTC/ herbswhat meds do you take?what meds do you take?

Nursing AssessmentNursing Assessment

Objective DataObjective Data::

General ObservationGeneral Observation

InspectInspect

AuscultateAuscultate

PercussPercuss

Palpate (always last)Palpate (always last)

Focused Health HistoryFocused Health History

NutritionNutrition AllergiesAllergies MedicationsMedications Cigarette/tobaccoCigarette/tobacco ETOH intakeETOH intake Recreational drug useRecreational drug use Stool characteristicsStool characteristics Urine characteristicsUrine characteristics Exposure to infectious Exposure to infectious

dz.dz. Recent stressful life Recent stressful life

eventsevents Possibility of PregnancyPossibility of Pregnancy

Techniques for ExamTechniques for Exam

Provide privacyProvide privacy Good lighting/appropriate temp in rmGood lighting/appropriate temp in rm Expose the abdomenExpose the abdomen Empty bladderEmpty bladder Position pt supine, arms by side & head on Position pt supine, arms by side & head on

pillow with knees slightly bent or on a pillowpillow with knees slightly bent or on a pillow Warm stethoscope & handsWarm stethoscope & hands Painful areas lastPainful areas last Distraction techniquesDistraction techniques

InspectionInspection

Overall observationOverall observation

Abd contour- flat, Abd contour- flat, scaphoid, round, scaphoid, round, protuberantprotuberant

Abd symmetry and skin Abd symmetry and skin color - note any masses, color - note any masses, striae, scars, veins, striae, scars, veins, pigmentationpigmentation

PulsationsPulsations

AuscultationAuscultation

Always done before Always done before percussion & percussion & palpationpalpation

Use diaphragm of Use diaphragm of stethoscopestethoscope

Listen lightlyListen lightly

Start with RLQStart with RLQ

AuscultationAuscultation

What makes a bowel sound?What makes a bowel sound? Note character & frequency of bowel Note character & frequency of bowel

sounds (5-30 times/minute)sounds (5-30 times/minute) Sounds like…..Sounds like….. Listen for 5 minutes before documenting Listen for 5 minutes before documenting

absent bowel soundsabsent bowel sounds Listen for bruits- aortic, renal, iliac, femoralListen for bruits- aortic, renal, iliac, femoral Hyper- gastroenteritis, obstruction, hungryHyper- gastroenteritis, obstruction, hungry Hypo- pregnancy, peritonitisHypo- pregnancy, peritonitis

PercussionPercussion

Gently tapping on the skin to create a Gently tapping on the skin to create a vibrationvibration

Detect fluid, gaseous distention and Detect fluid, gaseous distention and massesmasses

Tympany- gas (dominant sound because Tympany- gas (dominant sound because of air in sm intestine)of air in sm intestine)

Dullness- solid masses, distended bladderDullness- solid masses, distended bladder Percuss liver, spleen ,kidneysPercuss liver, spleen ,kidneys

Palpation of AbdomenPalpation of Abdomen

Light palpation- depress about 1 cm. Assess Light palpation- depress about 1 cm. Assess skin pulsations. Always done first- clockwiseskin pulsations. Always done first- clockwise

Deep palpation- depress skin about 5-8 cm.Deep palpation- depress skin about 5-8 cm.

Always assess tender areas last.Always assess tender areas last.

Watch pt’s expression during palpationWatch pt’s expression during palpation

Inspection Abnormal Inspection Abnormal FindingsFindings

Visible or distended veins- ascitesVisible or distended veins- ascites

Visible peristalsis- obstructionVisible peristalsis- obstruction

Spider nevi (cutaneous angiomas)- cirrhosisSpider nevi (cutaneous angiomas)- cirrhosis

Asymmetry/ Distention- mass or intestinal Asymmetry/ Distention- mass or intestinal obsructionobsruction

Color changes- jaundice, bluish/cyanoticColor changes- jaundice, bluish/cyanotic

Abnormal AuscultationAbnormal Auscultation

Absence/Hyperactive bowel sounds- Absence/Hyperactive bowel sounds- “borborygmi”“borborygmi”

Bruits- “swoosh”Bruits- “swoosh”

Peritoneal Friction Rub- rough, grating Peritoneal Friction Rub- rough, grating heard over liver & spleen- inflammation of heard over liver & spleen- inflammation of peritoneal surface from tumor, infection, peritoneal surface from tumor, infection, etc.etc.

Percussion Abnormal Percussion Abnormal FindingsFindings

Enlarged organs, palpable masses, Enlarged organs, palpable masses, distention, ascitesdistention, ascites

Marked tendernessMarked tenderness

Palpation Abnormal FindingsPalpation Abnormal Findings

Tenderness- rebound- done away from Tenderness- rebound- done away from painful area- done at end of exampainful area- done at end of exam

Masses- document location, size, shape, Masses- document location, size, shape, mobile, pulsating, smooth, nodular, firmmobile, pulsating, smooth, nodular, firm

Firmness or muscle guarding/rigidity- Firmness or muscle guarding/rigidity- intraabdominal bleeding- DO NOT intraabdominal bleeding- DO NOT CONTINUE TO PALPATE!!!!!!CONTINUE TO PALPATE!!!!!!

Special ProceduresSpecial Procedures

Fluid Wave- need 3 hands- feel for impulse of the Fluid Wave- need 3 hands- feel for impulse of the wave of fluid across the abdomen= asciteswave of fluid across the abdomen= ascites

Rebound Tenderness- Blumberg’s SignRebound Tenderness- Blumberg’s Sign

Iliopsoas Muscle Test- thigh muscle lift R leg and Iliopsoas Muscle Test- thigh muscle lift R leg and push down on R thigh= appendicitispush down on R thigh= appendicitis

Obturator Test- lift R leg and rotate at 90 Obturator Test- lift R leg and rotate at 90 degrees= muscle is irritated by appendicitisdegrees= muscle is irritated by appendicitis

Murphy’s Sign- “inspiratory arrest” palpate the Murphy’s Sign- “inspiratory arrest” palpate the liver should be painless= cholecystitisliver should be painless= cholecystitis

Special ProceduresSpecial Procedures

McBurney’s Point- RLQ midclavicular= McBurney’s Point- RLQ midclavicular= appendicitisappendicitis

Referred pain- location of pain is not Referred pain- location of pain is not necessarily where the involved organ is! necessarily where the involved organ is! May be felt where the organ was located in May be felt where the organ was located in fetal development ex: spleen= L shoulder fetal development ex: spleen= L shoulder pain/ kidney= groin pain pain/ kidney= groin pain

Hooking technique- palpate the liver- Hooking technique- palpate the liver- feeling for the liver edgefeeling for the liver edge

Special ProceduresSpecial Procedures

Cullen’s Sign- bluish discoloration Cullen’s Sign- bluish discoloration around the umbilicus EMERGENCY!!!around the umbilicus EMERGENCY!!!

Kehr’s Sign- abd pain radiating to R Kehr’s Sign- abd pain radiating to R shoulder= spleen or pancreatitisshoulder= spleen or pancreatitis

Sample DocumentationSample Documentation

Normal Exam-Normal Exam-

Abdomen soft, rounded and symmetric without Abdomen soft, rounded and symmetric without distention; no lesions or scars, or visible distention; no lesions or scars, or visible peristalsis. Aorta midline without bruit or visible peristalsis. Aorta midline without bruit or visible pulsation; umbilicus inverted and midline pulsation; umbilicus inverted and midline without herniation; bowel sounds present in all without herniation; bowel sounds present in all 4 quadrants. Liver, kidney and spleen non-4 quadrants. Liver, kidney and spleen non-palpable; no tenderness on palpation. Reports palpable; no tenderness on palpation. Reports good appetite; no constipation, nausea or good appetite; no constipation, nausea or diarrhea. Voiding well and denies laxative use.diarrhea. Voiding well and denies laxative use.