Assessment for Abdomen

The abdomen is bordered superiorly by the costal margins, inferiorly by the symphysis pubis and inguinal canals, and laterally by the anks. To perform an adequate as-assessment of the abdomen, the nurse needs to understand the anatomic divisions known as the abdominal quadrants, the abdominal wall muscles, and the internal anatomy of the abdominal cavity.

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Assessment Procedure Inspect the skin - Observe the coloration of the skin. Normal Findings a. Abdominal skin may be paler than the general skin tone because this skin is so seldom ex-posed to the natural elements. Abnormal findings a. Purple discoloration at the anks (Grey Turnersign) indicates bleeding within the abdominal wall, possibly from trauma to the kidneys, pancreas, or duodenum or from pancreatitis. b. The yellow hue of

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jaundice may be more apparent on the abdomen. c. Pale, taut skin may be seen with ascites (signicant abdominal swelling indicating uid accumulation in the abdominal cavity). d. Redness may indicate inammation.

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e. Bruises or areas of local discoloration are also abnormal. - Note the vascularity of the abdominal skin. a. Scattered ne veins may be visible. Blood in the veins located above the umbilicus ows toward the head; blood in the veins located below a. Dilated veins may be seen with cirrhosis of the liver, obstruction of the inferior vena cava, portal hypertension, or ascites. b. Dilated surface arterioles and capillaries

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the umbilicus ows toward the lower body. - Note any striae. a. Old, silvery, white striae or stretch marks from past pregnancies or weight gain are normal. with a central star (spider angioma) may be seen with liver disease or portal hypertension. a. Dark bluish-pink striae are associated with Cushings syndrome. b. Striae may also be caused by ascites, which stretches the skin.

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Ascites usually results from liver failure or liver disease. - Inspect for scars. Ask about the source of a scar, and use a centimeter ruler to measure the scars length. Document the location by quadrant and reference lines, shape, a. Pale, smooth, minimally raised old scars may be seen. a. Non-healing scars, redness, inammation. Deep, irregular scars may result from burns.

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length, and any specic characteristics (eg, 3cmvertical scar in RLQ 4 cm below the umbilicus and 5 cm left of the midline). - Look for lesions and rashes. a. Abdomen is free of lesions or rashes. Flat or raised brown moles, however, are normal and may be apparent. a. Changes in moles including size, color, and border symmetry. Any bleeding moles orpetechiae (reddish or

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purple lesions) may also be abnormal. Inspect the Umbilicus - Note the color of the umbilical area. a. Umbilical skin tones are similar to surrounding abdominal skin tones or even pinkish. a. Bluish or purple discoloration around the umbilicus (Cullens sign) indicates intra-abdominal bleeding.

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- Observe umbilical location. a. Midline at lateral line. a. A deviated umbilicus may be caused by pressure from a mass, enlarged organs, hernia, uid, or scar tissue. a. An everted umbilicus is seen with abdominal distention. An enlarged, everted umbilicus suggests umbilical

- Assess contour of umbilicus.

a. Recessed (inverted) or protruding no more than 0.5 cm; round or conical.

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hernia. Inspect Contour, Symmetry and Movement - To inspect abdominal contour, look across the abdomen at eye level from the clients right side, from behind the clients head, and from the foot of the a. Abdomen is at, rounded, or scaphoid (usually seen in thin adults). Abdomen should be evenly rounded. a. A generalized protuberant or distended abdomen may be due to air (gas) or uid accumulation. b. Distention below the

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bed. umbilicus may be due to a full bladder, uterine enlargement, or an ovarian tumor or cyst. c. Distention of the upper abdomen may be seen with masses of the pancreas or gastric dilation. a. Abdomen is a. Abdomen is

- To assess abdominal

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symmetry, look at the clients abdomen as he or she lies in a relaxed supine position. - To further assess the abdomen for herniation or diastasis recti, or to differentiate a mass within the abdominal wall from one below it, ask the client symmetry. asymmetry.

a. Abdomen does not bulge when client raises head.

a. A scaphoid (sunken) abdomen may be seen with severe weight loss or cachexia related to starvation or terminal illness.

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to raise the head. b. Asymmetry may be seen with organ enlargement, large masses, hernia, diastasis recti, or bowel obstruction. c. A hernia (protrusion of the bowel through the abdominal wall) is seen as a bulging in the abdominal wall.

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d. Diastasis recti appear as a bulging between a vertical midline separation of the abdominisrectus muscles. This condition is of little signicance. An incisional hernia may occur when a defect develops in the abdominal muscles

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because of a surgical incision. A mass within the abdominal wall is more prominent when the head is raised, whereas a mass below the abdominal wall is obscured. - Inspect abdominal movement when the client a. Abdominal respiratory movement a. Diminished abdominal respiration or change to

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breathes (respiratory movements). - Observe aortic pulsations. may be seen, especially in male clients. a. A slight pulsation of the abdominal aorta, which is visible in the epigastrium, extends full length in thin people. thoracic breathing in male clients may reect peritoneal irritation. a. Vigorous, wide, exaggerated pulsations maybe seen with abdominal aortic aneurysm.

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- Watch for peristaltic waves. a. Normally, peristaltic waves are not seen, although they may be visible in very thin people as slight ripples on the abdominal wall. a. Peristaltic waves are increased and progress in a ripple-like fashion from the LUQ to the RLQ with intestinal obstruction (especially small intestine). In addition, abdominal distention typically is present with intestinal wall obstruction.

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Auscultate for Bowel Sounds - Note the intensity, pitch, and frequency of the sounds. a. A series of intermittent, soft clicks and gurgles are heard at a rate of 5 to 30 per minute. Hyperactive bowel sounds that may be heard normally are the loud, a. Hypoactive bowel sounds indicate diminished bowel motility. Common causes include abdominal surgery or late bowel obstruction. b. Hyperactive bowel

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prolonged gurgles characteristic of stomach growling. These hyperactive bowel sound sare called borborygmi. sounds indicate increased bowel motility. Common causes include diarrhea, gastroenteritis, or early bowel obstruction. c. Decreased or absent bowel sounds signify the absence of bowel motility, which constitutes an

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emergency requiring immediate referral. d. Absent bowel sounds may be associated with peritonitis or paralytic ileus. High-pitched tinkling and rushes of high-pitched sounds with abdominal cramping usually indicate obstruction.

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Auscultate for Vascular Sounds and Friction Rubs - Use the bell of the stethoscope to listen for bruits (low-pitched, murmur like sound) over the abdominal aortaand renal, iliac, and femoral arteries. a. Bruits are not normally heard over abdominal aorta or renal, iliac, or femoral arteries. How-ever, bruits conned to systole may be normal in some clients a. A bruit with both systolic and diastolic components occurs when blood ow in an artery is turbulent or obstructed. This usually indicates aneurysm or arterial stenosis. If the

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depending on other differentiating factors. client has hypertension and you auscultate a renal artery bruit with both systolic and diastolic components, suspect renal artery stenosis as the cause. a. Venous hums are rare. However, an accentuated venous hum

- Using the bell of the stethoscope, listen for a venous hum in the

a. Venous hum is not normally heard over the epigastric and

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epigastric and umbilical areas. umbilical areas heard in the epigastric or umbilical areas suggests increased collateral circulation between the portal and systemic venous systems, as in cirrhosis of the liver a. Friction rubs are rare. If heard, they have a high-pitched, rough,

- Auscultate for a friction rub over the liver and spleen by listening over the

a. No friction rub over liver or spleen.

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right and left lower rib cage with the diaphragm of the stethoscope. grating sound produced when the large surface area of the liver or spleen rubs the peritoneum. They are heard in association with respiration. b. A friction rub heard over the lower right costal area is associated with hepatic abscess or

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metastases. c. A rub heard at the anterior axillary line in the lower left costal area is associated with splenic infarction, abscess, infection, or tumor. Percuss for Tone - Lightly and systematically a. Generalized a. Accentuated tympany

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percuss all quadrants. tympany predominates over the abdomen because of air in the stomach and intestines. Normal dullness is heard over the liver and spleen. b. Dullness may also be elicited over a nonevacuated descending colon. or hyperresonance is heard over a gaseous distended abdomen. b. An enlarged area of dullness is heard over an enlarged liver or spleen. c. Abnormal dullness is heard over a distended bladder, large masses, or ascites. d. If you suspect ascites,

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perform the shifting dullness and uid wave tests. Percuss the Liver - Percuss the span or height of the liver by determining its lower and upper borders. To assess the lower border, begin in the a. The lower border of liver dullness is located at the costal margin to 1 to 2 cm below.

Tip From the Experts:

If you cannot find the lower border of the liver, keep in mind that the lower border of liver

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RLQ at the mid-clavicular line (MCL) and percuss upward. Note the change from tympany to dullness. Mark this pointit is the lower border of liver dullness. - To assess the descent of the liver, ask the client to take a deep breath, and a. On deep inspiration, the lower border of liver dullness may dullness may be difficult to estimate when obscured by intestinal gas.

Tip From the Experts:

The upper border of liver dullness may be difficult

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then repeat the procedure. To assess the upper border, percuss over the upper right chest at the MCL and percuss downward, noting the change from lung resonance to liver dullness. Mark this pointit is the upper border of liver dullness. descend from 1 to 4 cm below the costal margin. The upper border of liver dullness is located between the left fifth and seventh intercostal spaces. to estimate if obscured by pleural uid or lung consolidation.

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Assessment for Abdomen

- Measure the distance between the two marks this is the span of the liver. a. The normal liver span at the MCL is 6 to 12 cm (greater in men and taller clients, less in shorter clients). a. Hepatomegaly, a liver span that exceeds normal limits (enlarged), is characteristic of liver tumors, cirrhosis, abscess, and vascular engorgement. b. Atrophy of the liver is indicated by a decreased span. c. A liver in a lower

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position than normal maybe caused by emphysema, whereas a liver in a higher position than normal may be caused by an abdominal mass, ascites, or a paralyzed diaphragm. A liver in a lower or higher position should have a normal span.

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- Repeat percussion of the liver at the midsternal line (MSL). Perform the Scratch Test - If you cannot accurately percuss the liver borders, perform the scratch test. Auscultate over the liver and, starting in the RLQ, a. The sound produced by scratching becomes more intense over the liver. a. An enlarged liver may be roughly estimated (not accurately) when more intense sounds outline a liver span or a. The normal liver span at the MSL is 4 to 8 cm.

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scratch lightly over the abdomen, progressing upward toward the liver. Percuss the Spleen - Begin posterior to the left mid-axillary line (MAL), and percuss downward, noting the change from lung resonance to splenic a. The spleen is an oval area of dullness approximately 7 cm wide near the left tenth rib, and slightly a. Splenomegaly is characterized by an area of dullness greater than 7 cm wide. The enlargement may result borders outside the normal range.

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dullness. posterior to the MAL. from traumatic injury, portal hypertension, and mononucleosis. a. On inspiration, dullness at the last left inter-space at the AAL suggests an enlarged spleen.

- A second method for detecting splenic enlargement is to percuss the last left interspace at the anterior axillary line (AAL) while the client takes a deep breath.

a. Normally, tympany (or resonance) is heard at the last left interspace.

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Perform Blunt Percussion on the Liver and Kidneys - To assess for tenderness in difcult-to-palpate structures, perform blunt (indirect st) percussion. Percuss the liver by placing your left hand at against the lowe rright rib cage. Use the ulnar side of your a. Normally, no tenderness is elicited. a. Tenderness elicited over the liver may be associated with inammation or infection (eg: hepatitis or cholecystitis).

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right st to strike your left hand. - Perform blunt percussion on the kidneys at the costovertebral angles (CVA) over the twelfth rib. a. Normally, no tenderness or pain is elicited or reported by the client. The examiner senses only a dull thud. a. Tenderness or sharp pain elicited over the CVA suggests kidney infection (pyelonephritis), renalcalculi, or hydronephrosis.

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Perform Light Palpation - Using the ngertips, begin palpation in a nontenderquadrant, and compress to a depth of 1 cm in a dipping motion. Then, gently lift the ngers and move to the next area. - To minimize the clients a. Nontender

a. No guarding;

a. Involuntary reex

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voluntary guarding (a tensing or rigidity of the abdominal muscles, usually involving the entire abdomen), see Display 183. Keep in mind that the rectus abdominis muscle relaxes on expiration. abdomen is soft. guarding is serious and reects peritoneal irritation. The abdomen is rigid and the rectus muscle fails to relax with palpation when the client exhales. It can involve all or part of the abdomen but is usually seen on the side (ie, right vs left, rather than

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upper or lower) because of nerve tract patterns. Right-sided guarding may be due to cholecystitis. Perform Deep Palpation - Deeply palpate all quadrants to delineate abdominal organs and a. Normal (mild) tenderness is possible over the xiphoid, a. Severe tenderness or pain may be related to trauma, peritonitis,

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detect subtle masses. Using the palmar surface of the ngers, compress to a maximum depth, (5to 6 cm). Perform bimanual palpation if you encounter resistance or to assess deeper structures. - Palpate for masses and their location, size (cm), aorta, cecum, sigmoid colon, andovaries with deep palpation. infection, tumors, or enlarged or diseased organs.

a. No palpable masses.

a. A mass detected in any quadrant may be

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shape,consistency, demarcation, pulsatility, tenderness, andmobility. Do not confuse a mass with a normally pal-pated organ or structure. Palpate the Umbilicus - Palpate the umbilicus and surrounding area for a. Umbilicus and surrounding area are a. A soft center of the umbilicus can be a due to a tumor, cyst, abscess, enlarged organ, aneurysm, or adhesions.

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swellings, bulges, or masses. free of swellings, bulges, or masses. potential for herniation. Palpation of a hard nodule in or around the umbilicus may indicate metastatic nodes from an occult gastrointestinal cancer.

Palpate the Aorta - Use your thumb and rst a. The normal aorta is a. A wide, bounding

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nger or use two hands and palpate deeply in the epigastrium, slightly to the left of midline. approximately 2.5 to 3.0 cm wide with a moderately strong and regular pulse. Possibly, mild tenderness may be elicited pulse may be felt with an abdominal aortic aneurysm. A prominent, laterally pulsating mass above the umbilicus, with an accompanying audible bruit, strongly suggests an aortic aneurysm.

Palpate the Liver

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- Palpate to note consistency and tenderness. To palpate bimanually, stand at the clients right side and place your left hand under the clients back at the level of the eleventh to twelfth ribs. Lay your right hand parallel to the right costal margin (your ngertips should point a. The liver is usually not palpable, although it may be felt in some thin clients. If the lower edge is felt, it should be rm, smooth, and even. Mild tenderness maybe normal. a. A hard, rm liver may indicate cancer. Nodularity may occur with tumors, metastatic cancer, late cirrhosis, or syphilis. Tenderness may be from vascular engorgement (eg, congestive heart failure), acute hepatitis, or abscess.

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toward the clients head). Ask the client to inhale, then compress upward and inward with your ngers. To palpate by hooking, stand to the right of the clients chest. Curl (hook) the ngers of both hands over the edge of the right costal margin. Ask the client to take a deep breath, and b. A liver more than 1 to 3 cm below the costal margin is considered enlarged (unless pressed down by the diaphragm). Enlargement may be due to hepatitis, liver tumors, cirrhosis, and vascular engorgement.

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gently, but rmly, pull inward and upward with your ngers. Palpate the Spleen - Stand at the clients right side, reach over the abdomen with your left arm and place your hand under the posterior lower ribs. Pull a. The spleen is seldom palpable at the left costal margin; rarely, the tip is palpable in the a. A palpable spleen suggests enlargement (up to three times the normal size), which may result from trauma,

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up gently. Place your right hand below the left costal margin with the ngers pointing toward the clients head. Ask the client to inhale, and press inward and upward as you provide support with your other hand. - Alternatively, asking the presence of a low, at diaphragm (eg,chronic obstructive lung disease) or with deep diaphragmatic descent on inspiration. mononucleosis, chronic blood disorders, and cancers. The splenic notch maybe felt, which is an indication of splenic enlargement.

a. If the edge of the

a. The spleen feels soft

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client to turn onto the right side may facilitate splenic palpation by moving the spleen downward and forward. Document the size of the spleen in centimeters below the left costal margin. Also note consistency and tenderness. spleen can be palpated, it should be soft and nontender. with a rounded edge when it is enlarged from infection. It feels rm with a sharp edge when it is enlarged from chronic disease. b. Tenderness accompanied by peritoneal inammation or capsular stretching is associated with splenic

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enlargement. Palpate the Kidneys - To palpate the right kidney, support the right posterior ank with your left hand, and place your right hand in the RUQ just below the costal margin at the MCL. To capture the a. The kidneys are normally not palpable. Sometimes, the lower pole of the right kidney may be palpable by the capture method a. An enlarged kidney may be due to a cyst, tumor, or hydronephrosis. It can be differentiated from splenomegaly by its smooth rather than

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kidney, ask the client to inhale. Then, compress your ngers deeply during peak inspiration. Ask the client to exhale and hold the breath briey. Gradually release the pressure of your right hand. If you have captured the kidney, you will feel it slip beneath your ngers. To palpate the left because of its lower position. If palpated, it should feel rm, smooth, and rounded. The kidney may or may not be slightly tender. sharp edge, absence of a notch, and overlying tympany on percussion.

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kidney, reverse the procedure. Palpate the Urinary Bladder - Palpate for a distended bladder when the clients history or other ndings warrant (eg, dull percussion noted over the symphysis pubis). Begin at the a. Normally not palpable. a. A distended bladder is palpated as a smooth, round, and somewhat rm mass, extending as far as the umbilicus. It may be further validated

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symphysis pubis, and move upward and outward to estimate bladder borders. by dull percussion tones.

Validate the abdominal assessment data that you have collected. This is necessary to verify that the data are reliable and accurate. Document the assessment data following the health care facility or agency policy.

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