Susan Roberts, MS, RD, CNSC Andrea JeVenn, RD, LD, CNSC ABDOMINAL EXAMINATION AND THE ASSESSMENT OF FLUID ACCUMULATION.

Susan Roberts, MS, RD, CNSC

Andrea JeVenn, RD, LD, CNSC

ABDOMINAL EXAMINATIONAND THE

ASSESSMENT OF FLUID ACCUMULATION

THEABDOMINAL EXAMINATION

ANATOMY AND TERMINOLOGY

RUQ Right lobe of liver, gallbladder, pylorus, first 3 parts of duodenum, head of pancreas, right suprarenal (adrenal) gland, right kidney, right colic (hepatic) flexure, sup. part of ascending colon, right half of transverse colon

RLQ Cecum, appendix, most of ileum, inferior part of ascending colon, right ovary, right uterine tube, right ureter

LLQ Sigmoid colon, inf part of descending colon, left ovary, left uterine tube, left ureter

LUQ Left lobe of liver, spleen, most of stomach, jejunum & proximal ileum, body & tail of pancreas, left suprarenal (adrenal) gland, left kidney, left colic (splenic) flexure, sup part of descending colon, left half of transverse colon

COMPONENTS OF EXAM

Inspection• Visual review

• Assess symmetry and contour

Auscultation• Assess bowel and vascular sounds

• Done prior to palpation

Percussion• assess location & density of underlying body

masses/organs, gas/fluid patterns

AUSCULTATION

Use diaphragm of stethoscope

Begin in RLQ (ileo-cecal valve)

Listen in each quadrant• What are bowel sounds?

• Gas and fluid movement• Active

• Hypoactive

• Absent

BOWEL SOUNDSHyperactive

• Increased motility

• Stenosis

• Early SBO

• Resolving ileus

• Gastroenteritis

Hypoactive• Decreased motility

• Inflammation

• Paralytic ileus

• Peritonitis

• Surgical manipulation

• Late SBO

• Lower lobe pneumonia

PERCUSSION

Light tapping on abdomen• Assess size and position of solid organs

• Differentiate gas versus liquid vs solids

Tympany

Dullness

ILEUSAbsence of peristalsis or function

• Lack of mechanical issue

Causes• Peritonitis• Sepsis• Medications, especially narcotics• Metabolic disturbances

• Hyperglycemia and hypokalemia

Absent or hypoactive BS

Abdominal distention

ILEUS MILD ILEUS

ILEUS ILEUS IN NEONATE

BOWEL OBSTRUCTIONDefined as a partial or complete blockage

Causes

• Extrinsic

• Adhesions, volvulus, or hernias

• Intrinsic

• Tumor, stricture, stenosis

• Intraluminal

• Bezoars, fecal material, gallstones

BOWEL OBSTRUCTIONGeneral signs & symptoms

• Distention• Hyperactive or high

pitched BS• Minimum rebound• Crampy pain

Tests• Abdominal film• CT• UGI and/or small

bowel series

SITE OF OBSTRUCTION

Proximal• Acute onset

• Greater vomiting

• Bilious emesis

• Less distention

Distal• Less vomiting

• Greater explosive diarrhea

• Greater distention

POSSIBLE OBSTRUCTIONS

IMAGING STUDY OF OBSTRUCTION

Barium was instilled through a nasogastric tube

Picture shows loops of bowel >4cm in diameter

Green arrow shows transition point

ILEUS VS OBSTRUCTION

Ileus• No source of obstruction

• Gas in colon/rectum

• Distention but without pain

• May have bowel sounds

ASSESSING FLUID ACCUMULATION

WHAT IS FLUID RETENTION?

Abnormal retention of fluid in interstitial spaces and cavities (e.g., peritoneal/abdominal cavity)

• may not clinically manifest until it accounts for at least 10% of body weight or fluid volume is increased by 2.5-3 liters

• fluid accumulation around the heart, in the lungs, small pockets of ascites, or hematomas may only be seen on imaging studies

Braunwald, Loscalzo. Ch 36: Edema. In: Longo DL, Kasper DL, et al. Harrisons Principles of Internal Medicine; 2012 Epocrates: Evaluation of Peripheral Edema; accessed 11/26/14Sterns RH. Clinical manifestations and diagnosis of edema in adults; UpToDate 1/30/14 Ch 15: I have a patient with edema. How do I determine the Cause? In: Symptom to Diagnosis: An Evidence-Based Guide; 2009

Causes Conditions Associated with Fluid Accumulation

Increased capillary hydrostatic pressure Hypervolemia; kidney disease, pregnancy, CHF

Loss of plasma proteins Kidney disease, liver disease, burn victims, malabsorption, malnutrition

Obstruction of lymphatic circulation

Obstructing tumor, infection, damages to the lymph nodes or lymph node removal (cancers)

Increased capillary permeability

Usually from inflammatory response or response to infections

ACADEMY / ASPEN CLINICAL CHARACTERISTICS – EDEMA / FLUID ACCUMULATION

Context Acute Illness or Injury

Chronic Illness or Social / Environmental Circumstances

Malnutrition Moderate Severe Moderate Severe

Edema Mild Moderate to severe

Mild Severe

White et al, Characteristics for identification/documentation of adult malnutrition; JPEN 2012

• Weight loss is frequently masked by fluid retention and weight gain may be present

• If severe, can also mask evaluation of muscle/fat loss

• Usually SUPPORTIVE evidence

- RARELY ever directly related to malnutrition

White et al, Characteristics for identification/documentation of adult malnutrition; JPEN 2012

ACADEMY / ASPEN CLINICAL CHARACTERISTICS – EDEMA / FLUID ACCUMULATION

ASSESSING FLUID RETENTION

• Primarily found in dependent areas such as the sacrum, ankles, feet, calves, scrotum, vulva

• The clinician may evaluate generalized or localized fluid accumulation during a physical exam

• Localized:

• extremities, abdomen (ascites), vulva/scrotal area

• Generalized:

• if severe, is referred to as anasarca

DEPENDENT EDEMA – AMBULATORY PATIENTS: LEGS, ANKLES, FEET

DEPENDENT EDEMA – BED BOUND PATIENTS: SCROTUM, VULVA, SACRUM

Additional fluid

OTHER AREAS:EDEMA AND ASCITES

ASSESSMENT STRATEGY

• Perform general survey, then head-to-toe

• Use inspection and palpation• gloves optional

• Determine if onset is acute vs chronic• Acute: < 72 hours

• Chronic: better? worse? same?

• Correlate physical findings of fluid accumulation with other evidence • vital signs, input/output records, labs, weight, history,

imaging studies

Severity of edema is rated on a scale from +1 to +4

Press firmly but gently with your thumb for at least 5 seconds over

• the dorsum of the foot

• behind each malleolus

• over the shins

PALPATION TECHNIQUE

Grade

Depth

Description

0none No impression or distortion

observed, bone structure easily identified

1+ 2 mm or less

Slight pitting without distortion, rapidly disappears

2+ 2 – 4 mm

Somewhat deeper pit, distortion not easily apparent, disappears

10-25 seconds later

3+ 4 – 6 mm

Noticeably deep pitting, entire extremity looks full, swollen;

indentation can last longer than 1 minute

4+ 6 – 8 mmVery deep pitting, extremity is

grossly misshapen, indentation lasts 2-5 minutes

Table adapted from: G

rading: Pitting Edema - http://

www.med-health.net/Edem

a-Grading.htm

l

mild

severe

moderate

FEASIBILITY OF ACCESSING DATA IN HOSPITALIZED PATIENTS…

• Cross-sectional survey at 4 different hospitals: 2 tertiary teaching,1 urban, 1 rural; included 262 adults

• Determined availability of data to support the proposed Academy/ASPEN malnutrition characteristics

• Data on edema available at time of nutrition assessment

• All patients – 84.4%, Non-ICU – 85.9%, ICU – 82.7%

• Edema used as one of the characteristics to define malnutrition

• All patients – 26.6%, Non-ICU – 16.2%, ICU – 39.1%

Nicolo et al. JPEN 2013

SUMMARY

• Nutritional and medical history, & current medical picture must be considered before determining whether fluid accumulation is a relevant characteristic to use in identifying malnutrition

• Many patients have fluid accumulation but not all are malnourished

• RARELY a direct result of malnutrition

• Fluid accumulation may not always be readily visible

• Fluid accumulation will falsely increase weight / mask weight loss and can prevent muscle mass / SQ fat assessment

• Continue to partner with nurses, physicians and other health care team members to enhance assessment of fluid status