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Abdomen AssessmentAbdomen Assessment
D. Tanner, RN, MSND. Tanner, RN, MSN
NUR 211NUR 211Fall SemesterFall Semester
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Anatomy of the AbdomenAnatomy of the Abdomen
4 Quadrants RUQ, RLQ, LUQ,4 Quadrants RUQ, RLQ, LUQ,LLQLLQ
MidlineMidline
9 Regions9 Regions-- epigastric,epigastric,umbilical, suprapubicumbilical, suprapubic
The word "abdomen" has aThe word "abdomen" has acurious story behind it. Itcurious story behind it. Itcomes from the Latincomes from the Latin"abdodere", to hide. The idea"abdodere", to hide. The ideawas that whatever was eatenwas that whatever was eatenwas hidden in the abdomen.was hidden in the abdomen.
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4 Quadrants4 Quadrants
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9 Regions9 Regions
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Location! Location! Location!Location! Location! Location!
RUQRUQ
liverliver
gallbladdergallbladderduodenum (smallduodenum (smallintestine)intestine)
pancreas headpancreas head
right kidney and adrenalright kidney and adrenal
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Location! Location! Location!Location! Location! Location!
RLQRLQ
cecumcecum
appendixappendix
right ovary and tuberight ovary and tube
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Location! Location! Location!Location! Location! Location!
LLQLLQ
sigmoid colonsigmoid colonleft ovary and tubeleft ovary and tube
LUQLUQ
stomachstomachspleenspleenpancreaspancreasleft kidney and adrenalleft kidney and adrenal
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GI Variations Due to AgeGI Variations Due to Age
AgingAging-- should not affectshould not affectGI function unlessGI function unlessassociated with a diseaseassociated with a disease
processprocess
Decreased: salivation,Decreased: salivation,sense of taste, gastricsense of taste, gastric
acid
secretion,acid
secretion,esophageal emptying,esophageal emptying,liver size, bacterial floraliver size, bacterial flora
Increased: constipation!Increased: constipation!
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GI Variations with pregnancyGI Variations with pregnancy
Decrease in gastricDecrease in gastricmotilitymotility
High incidence of N, VHigh incidence of N, V
(r/t pregnancy hormones)(r/t pregnancy hormones)and heartburn or acidand heartburn or acidrefluxreflux
Bowel sounds diminishedBowel sounds diminishedr/t enlarged uterusr/t enlarged uterusdisplacing intestines
displacing intestines
Linea nigraLinea nigra-- increasedincreasedpigmentation of abdpigmentation of abdmidlinemidline
Striae GravidarumStriae Gravidarum
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Nursing HistoryNursing History -- AbdomenAbdomen
Subjective DataSubjective Data::Ask about:Ask about:AppetiteAppetiteWt gain or lossWt gain or lossDysphagiaDysphagiaIntolerance to certainIntolerance to certainfoodsfoodsA
nyAbd
ominal Pain ofA
nyAbd
ominal Pain ofNausea and VomitingNausea and VomitingBowel movementsBowel movementsAny past abdominalAny past abdominalproblemsproblems
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Nursing HistoryNursing History
Infants and ChildrenInfants and Children
Ask:bottle or breast fed, any table foods,Ask:bottle or breast fed, any table foods,how often & how well & how much thehow often & how well & how much thebaby eat, any problems with constipation,baby eat, any problems with constipation,c/o of any abdominal painc/o of any abdominal pain
TeenagersTeenagers--
Ask: nutritional assessment, activity &Ask: nutritional assessment, activity &exercise patterns, recent wt. loss or gainexercise patterns, recent wt. loss or gain
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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 forhow often do you take anything forconstipation? Rx / OTC/ herbsconstipation? Rx / OTC/ herbs
what meds do you take?what meds do you take?
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Nursing AssessmentNursing Assessment
Objective DataObjective Data::
General ObservationGeneral Observation
InspectInspect
AuscultateAuscultate
PercussPercussPalpate (always last)Palpate (always last)
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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 dz.Exposure to infectious dz. Recent stressful lifeRecent stressful life
eventsevents Possibility of PregnancyPossibility of Pregnancy
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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 onPosition pt supine, arms by side & head onpillow 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
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InspectionInspection
Overall observationOverall observation
Abdcontour
Abdcontour-- flat,flat,scaphoid, round,scaphoid, round,
protuberantprotuberant
Abd symmetry and skinAbd symmetry and skin
colorcolor -- note any masses,note any masses,striae, scars, veins,striae, scars, veins,pigmentationpigmentation
PulsationsPulsations
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AuscultationAuscultation
Always done beforeAlways done beforepercussion &percussion &
palpationpalpation
Use diaphragm ofUse diaphragm ofstethoscopestethoscope
Listen lightlyListen lightly
Start with RLQStart with RLQ
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AuscultationAuscultation
What makes a bowel sound?What makes a bowel sound?
Note character & frequency ofbowel sounds (5Note character & frequency ofbowel sounds (5--
30 times/minute)30 times/minute) Sounds like..Sounds like..
Listen for 5 minutes before documenting absentListen for 5 minutes before documenting absentbowel soundsbowel sounds
Listen for bruitsListen for bruits-- aortic, renal, iliac, femoralaortic, renal, iliac, femoral HyperHyper-- gastroenteritis, obstruction, hungrygastroenteritis, obstruction, hungry
HypoHypo-- pregnancy, peritonitispregnancy, peritonitis
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PercussionPercussion
Gently tapping on the skin to create aGently tapping on the skin to create avibrationvibration
Detect fluid, gaseous distention andDetect fluid, gaseous distention andmassesmasses
TympanyTympany-- gas (dominant soundbecausegas (dominant soundbecause
of air in sm intestine)of air in sm intestine)
DullnessDullness-- solid masses, distendedbladdersolid masses, distendedbladder
Percuss liver, spleen ,kidneysPercuss liver, spleen ,kidneys
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Palpation ofAbdomenPalpation ofAbdomen
Light palpationLight palpation-- depress about 1 cm. Assess skindepress about 1 cm. Assess skinpulsations. Always done firstpulsations. Always done first-- clockwiseclockwise
Deep palpationDeep palpation-- depress skin about 5depress skin about 5--8 cm.8 cm.
Always assess tender areas last.Always assess tender areas last.
Watch pts expression during palpationWatch pts expression during palpation
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Inspection Abnormal FindingsInspection Abnormal Findings
Visible or distended veinsVisible or distended veins-- ascitesascites
Visible peristalsisVisible peristalsis-- obstructionobstruction
Spider nevi (cutaneous angiomas)Spider nevi (cutaneous angiomas)-- cirrhosiscirrhosis
Asymmetry/ DistentionAsymmetry/ Distention-- mass or intestinalmass or intestinalobsructionobsruction
Color changesColor changes-- jaundice,
bluish/cyanoticjaun
dice,
bluish/cyanotic
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Abnormal AuscultationAbnormal Auscultation
Absence/Hyperactive bowel soundsAbsence/Hyperactive bowel sounds--borborygmiborborygmi
BruitsBruits-- swooshswoosh
Peritoneal Friction RubPeritoneal Friction Rub-- rough, grating heardrough, grating heardover liver & spleenover liver & spleen-- inflammation of peritonealinflammation of peritonealsurface from tumor, infection, etc.surface from tumor, infection, etc.
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Percussion Abnormal FindingsPercussion Abnormal Findings
Enlarged organs, palpable masses,Enlarged organs, palpable masses,distention, ascitesdistention, ascites
Marked tendernessMarked tenderness
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Palpation Abnormal FindingsPalpation Abnormal Findings
TendernessTenderness-- reboundrebound-- done away from painfuldone away from painfulareaarea-- done at end of examdone at end of exam
MassesMasses-- document location, size, shape, mobile,document location, size, shape, mobile,pulsating, smooth, nodular, firmpulsating, smooth, nodular, firm
Firmness or muscle guarding/rigidityFirmness or muscle guarding/rigidity--intraabdominal bleedingintraabdominal bleeding-- DO NOT CONTINUEDO NOT CONTINUETO PALPATE!!!!!!TO PALPATE!!!!!!
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Special ProceduresSpecial Procedures
Fluid WaveFluid Wave-- need 3 handsneed 3 hands-- feel for impulse offeel for impulse ofthe wave of fluid across the abdomen= ascitesthe wave of fluid across the abdomen= ascites
Rebound TendernessRebound Tenderness-- Blumbergs SignBlumbergs Sign
Iliopsoas Muscle TestIliopsoas Muscle Test-- thigh muscle lift R leg andthigh muscle lift R leg andpush down on R thigh= appendicitispush down on R thigh= appendicitis
Obturator TestObturator Test-- lift R leg and rotate at 90lift R leg and rotate at 90degrees= muscle is irritatedby appendicitisdegrees= muscle is irritatedby appendicitis
Murphys SignMurphys Sign-- inspiratory arrest palpate theinspiratory arrest palpate the
liver shouldbe painless= cholecystitisliver shouldbe painless= cholecystitis
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Special ProceduresSpecial Procedures
Cullens SignCullens Sign-- bluish discoloration aroundbluish discoloration aroundthe umbilicus EMERGENCY!!!the umbilicus EMERGENCY!!!
Kehrs SignKehrs Sign-- abd pain radiating to Rabd pain radiating to Rshoulder= spleen or pancreatitisshoulder= spleen or pancreatitis
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