Abdominal Assessment

NUR 242 Dr. Fran Anderson

Abdomen

Not a system to itself Largest cavity of the body Contains structures from the digestive system and other body systems Large oval cavity inferior to the diaphragm and superior to the pelvic floor Joined at the midline by a tendinous seam Linea alba Contains solid and hollow viscera

Maintain a characteristic shape

Liver Spleen Pancreas Adrenal glands Kidneys Uterus Ovaries

Solid Viscera

Hollow Viscera Shape depends on contents Stomach Gallbladder Small intestine Colon Bladder

Related Structures
Peritoneum
A serous membrane, lines the cavity and forms a protective cover for many abdominal structures Visceral Parietal

Aorta

Abdominal Vasculature and Deep Structures.

Kidneys
Located retroperitoneal or posterior to the abdominal contents Costoverterbral angle (CVA)
The 12 rib forms an angle with the vertebral column Left kidney lies at the 11th and 12 ribs Right kidney at the 12th rib and may be palpable, 1-2 cm lower than left kidney

The Urinary System. Relationship of the Kidneys to the Vertebrae

Spleen
Soft mass of lymphoid tissue On the posteriorlateral wall of the abdominal cavity Parallel to the 10th rib and lateral to midaxillary line

Anatomic Structures of the Abdominal Cavity

 Anatomic Structures of the Abdominal Cavity

Landmarks for Assessment

Surface Landmarks
Xiphoid process Costal margin Umbilicus Iliac crests Symphysis Pubis Four Abdominal muscle
External Oblique Internal oblique Transverse abdominis Rectus abdominis

Landmarks of the Abdomen

Mapping: Four Quadrants vs Nine Regions

Think Anatomically:

Think anatomically!

Imagine what organs live in the area that you are examining.

By thinking in anatomic terms, you will remind yourself of what resides in a particular quadrant and therefore what might be identifiable during both normal and pathologic states.

Four Quadrants - Landmarks

Midsternal line From xiphoid process through umbilicus to pubic bone Horizontal line Perpendicular to the first line, through the umbilicus Two lines form four equal quadrants of the abdomen
RUQ RLQ LUQ LLQ

Abdomen

Four Quadrants - Location

Quadrants named
Right upper quadrant (RUQ) Right lower quadrant (RLQ) Left upper quadrant (LUQ) Left lower quadrant (LLQ)

Four Quadrant Method vs. Nine Regions Method

Nine regions

Subjective Data Health History Questions

Appetite (weight gain Bowel habits or weight loss) Past abdominal Dysphagia history

Food intolerance
Abdominal pain Nausea/vomiting (medications, GI disease)

Medications (prescribed and OTC)

Nutritional assessment (24 hour recall)

Equipment
Examination gown and drape Examination gloves Examination light Stethoscope Skin marker Metric ruler Tissues Tape measure

Physical Assessment of the Abdomen

NOTE CHANGE IN SEQUENCING
Techniques

1. Inspection 2. Auscultation 3. Percussion 4. Palpation

INSPECTION

Inspection of the Abdomen

The patient should be lying flat with side and relaxed. Observe for:
Contour of the abdomen Skin and subcutaneous tissue Umbilicus Peristalsis and pulsations

Inspect the Abdomen

Contour - flat to round, describes nutritional state Symmetry - bulging, visible mass, asymmetry Umbilicus - midline and inverted, inflammation, hernia Skin - smooth even with homogenous color Pulsation - slight pulsation from aorta in epigastric region Peristaltic wave - peristaltic waves in thin individuals Hernia (cough) Venous pattern Cirrhosis (Caput Medusae) Hair distribution - pubic hair diamond shaped in males and inverted triangle shape in females-patterns altered with endocrine, or hormone abnormalities, chronic liver disease Demeanor relaxed quietly on table with benign facial expression and slow even respirations

Contour of the Abdomen

Flat

Contour of the Abdomen

Rounded (convex)

Contour of the Abdomen

Scaphoid (Concaved)

Contour of the abdomen

Protuberant

Mnemonics - The 9- Fs of Abdominal Distention: Fat, Fluid, Feces, Fetus, Flatus, Fibroid, Full bladder, False pregnancy, Fatal tumor

Fully rounded or distended, umbilicus inverted

Distended lower half Distended lower half

Fully rounded or distended, umbilicus inverted

Fully rounded or distended, umbilicus everted Fully rounded or distended, umbilicus everted

Distended lower third Distended lower third

Scaphoid

Distended upper half

Umbilical Hernia

Usually Seen in Obesity, Pregnancy, and Ascites

Striae Stretch Marks

Silvery white, linear, jagged, marks about 1 to 6 cm long. They occur when elastic fibers in the reticular layer of the skin are broken after rapid or prolonged streatching, as in pregnancy, excesive weight gain, or ascites

Dilated Venous Pattern Over the Right Upper Abdomen

Caput Medusae

Linea Nigra Third Trimester of Pregnancy

Most Commonly on the Trunk and Upper Extremities

Spider Angiomata

Documentation

AUSCULTATION

Auscultation of the Abdomen

All Quadrants

Bowel sounds (diaphragm) Vascular sounds (bell) listen for bruits Friction rubs

Auscultate Bowel Sounds

Auscultate:
Use diaphragm of stethoscope prior to palpation All four quadrants starting in RLQ Note: Frequency and character of bowel sounds.

Normal:
Bowel sound are irregular, high-pitched, gurgling or clicking sounds occurring 5-30 per minute An occasional borborygmus (loud prolonged gurgle) may be heard

Procedure: Auscultate Bowel Sounds

Hold stethoscope lightly against skin Start in RLQ at the ileocecal valve (bowel sounds are normally always present here) Note frequency and characteristics of sounds Bowel sound are irregular, highpitched, gurgling sounds occurring 5-30 per minute Dont bother to count

If abdomen is silent must listen for 5 minutes before proclaiming no bowel sounds
An occasional borborygmi (loud prolonged gurgle) may be heard.

Abnormal Bowel Sounds

Hyperactive bowel sounds Loud, high-pitched and rushing - Signal increased motility Common with gastroenteritis and diarrhea Hypoactive bowel sounds Slow and sluggish Signal decreased motility Common after abdominal surgery Absent bowel sounds Paralytic ileus or bowel obstruction High pitched tinkling sounds Suggest intestinal fluid, and air under pressure, as in early obstruction

Vascular Sounds Use Bell of Stethoscope

Sites to Auscultate for Bruits:

Aorta, Renal Arteries, Iliac Arteries, and Femoral Arteries

Vascular Sounds
Normal
No vascular or friction sounds

Bruits
Pulsatile and blowing May indicate arterial occlusion

Venous hum
Soft, continuous and low-pitched Indicates increased portal tension (Cirrhosis)

Friction rub
High pitched, grating sound Caused by the rubbing together of organs or an organ rubbing on the peritoneum Indicate inflammation of peritoneal surface of the organ from tumor, infection, or infarction

PERCUSSION

Percuss the Abdomen

General tympany
Liver span
Usual technique Scratch test

Splenic dullness Costovertebral angle (CVA) tenderness

Percuss - General Tympany

Percuss
Lightly in all four quadrants to determine the prevailing amount of: Tympany Dullness Hyperresonance

Start in RLQ, and percuss in all quadrants

Abdominal Sounds
Tympany (normal sound)
Loud hallow sound Should predominate, air rises to the surface

Dullness (fluid-filled, dense tissue)

Occurs over distended bladder, adipose tissue, fluid, mass, liver & spleen

Hyperresonance (air-filled)
Louder than tympany Is present with gaseous distention

Percussion of the Liver

Resonance Resonance Dullness

Dullness Tympany Tympany Tympany

To determine the upper and lower borders of the liver at the midclavicular line

Technique Percussion of the Liver

Peruss downward from fourth intercostal space along the MCL until the sound changes to dullness. - Mark the spot usually the 5-7th intercostal space Mark point Percuss upward, begin percussion at level of umbilicus and move up toward ribcage along MCL until the sound changes from tympany to dull sound normally at the right costal margin Mark point Normal liver span = 6 -12 cm

Liver Span Normally 6 to 12 cm

Scratch Test To Detect Liver Size

Place stethoscope over liver When the scratching sound in your stethoscope becomes magnified you will have crossed the border from a hollow organ to a solid organ

Similar maneuvers will determine the upper edge.

With one finger scratch short strokes over the abdomen, starting in RLQ and moving progressively up toward the liver

Percussing the Spleen

(Splenic Dullness)

Percussing the Spleen (Splenic Dullness)

Percuss in several directions. Percuss for a dull note from the 6th to10th intercostal space just posterior to the left midaxillary line. Spleen is often obscured by the stomach contents. The area of splenic dullness normally is not wider than 7 cm in the adult

Percussing the Spleen (Splenic Dullness) Alternate Technique

Percuss in lowest interspace in the left midaxillary line
Should hear tympany

Have patient take a deep breath Percuss again in lowest interspace in the left midaxillary line
Should hear tympany

If you hear dullness then spleen is enlarged With splenic enlargement tympany change to dullness as the spleen is brought forward and downward with inspiration (splenic percussion sign)

Spleen
Spleen is soft and located deep in the peritoneal cavity

Not palpable in normal adult.

Describe splenic enlargement according to the number of cms it extends below the left costal margin.

PALPATION

Palpation of Abdomen
Measures to enhance muscle relaxation Palpate abdomen
Light palpation Deep palpation Bimanual palpation

Spleen

Kidneys
Aorta Special procedures
Rebound tenderness (Blumberg sign)
Inspiratory arrest (Murphys sign) Psoas muscle test

Liver
Usual technique Hooking technique

Light/Deep/Bimanual

Palpation

Abdominal Structures Frequently Felt as Masses

Light Palpation
With first four finger depress skin about 1 cm Make gentle rotary motion, sliding the fingers and skin together over all four quadrants Lift fingers do not drag to next location Objective is not to search for organs but to get a general overall impression of the skin surface and superficial musculature Watch for: Muscle guarding, rigidity, large masses, tenderness

Normal Abdomen Soft smooth Nontender pain-free

Deep Palpation

Using the same technique, push down about 5 to 8 cm (2 to 3 inches). Moving clockwise exploring the entire abdomen.

Bimanual Palpation
To overcome the resistance of a very large or obese abdomen Place your two hands on top of each other. The top hand does the pushing, the bottom hand is relaxed and can concentrate on the sense of palpation

Diastasis Recti in Pregnancy

A. Normal position in nonpregnant female. B. Diastasis recti abdominis in pregnant female.

Palpate the Liver

Palpate to detect enlargement, pain, consistency Stand on right side of client Place left hand under the lower portion of the ribs (ribs 11 & 12) Apply slight pressure in an upward motion under the ribs on the right side
Caution:You should try to palpate liver by superficial palpation and not deep palpation. Liver edge is just hugging anterior abdominal wall. With superficial palpation, let the liver edge come and touch your fingers with deep breathing rather than you going after liver.

Palpate the Liver

Ask client to take a deep breath Normally, the liver is not palpable, except in thin clients

Alterative Technique Liver - Hook Technique

Hook your fingers over the costal margin from above. Ask the person to take a deep breath. Stand at the person's shoulder and swivel you body to the right so that you face the persons feet. Try to feel the liver edge bump your fingertips.

Liver - Abnormal Findings

Pain (indicates): Gallbladder disease Hepatitis Enlargement of the liver (hepatomegaly) seen with CHF Nodules Occur with cirrhosis or metastasis carcinoma

Palpation of the Spleen

Palpated to detect enlargement Careful palpation is required because the spleen is fragile and sensitive The spleen is not normally palpable

Palpation of the Spleen Technique

Reach left hand over abdomen and behind the left side at the 11th and 12th rib lift for support Place right hand obliquely on the LUQ with fingers pointing toward the left axilla, just inferior to the rib margin Push hand deeply down and under the left costal margin, ask patient to take a deep breath You should feel nothing firm

Palpation of the Spleen Abnormal Findings

Splenomegaly Occurs in acute infections such as Infectious Mononucleosis Caution: Repeated rough multiple examinations can cause splenic rupture and hemorrhage. You should try to palpate spleen by superficial palpation and not deep palpation. Splenic tip is just hugging anterior abdominal wall. With superficial palpation, let the splenic tip come and touch your fingers with deep breathing rather than you going after spleen.

Palpation of the Kidneys

Palpation of the Kidneys

Palpating the Left Kidney

Additional Procedures
Aorta Rebound tenderness Blumbergs Sign Inspiratory arrest : Gallbladder Murphy's sign: Appendix Psoas sign Ascites: fluid wave

Palpation of Aorta
Using your opposing thumb and fingers, palpate the aortic pulsation in the upper abdomen slightly to the left of midline.
Normally it is 2.5 to 4 cms wide in the adult and pulsates in an anterior direction
Normal = 2.5 to 4 cms

Rebound Tenderness (Blumbergs Sign)

Position the patient supine Place your hands gently on the RLQ at McBurneys point Located about midway between the umbilicus and the anterior superior iliac crest Hold hand at a 90% angle, push down slowly and deeply, then lift up quickly. Normal response is no pain on release of pressure Perform this test at the end of the examination, because it can cause sever pain and muscle rigidity

Mc Burneys point Halfway between umbilicus and right iliiac crest

Rebound Tenderness (Blumbergs Sign)

Sharp stabbing pain indicates: peritoneal irritation, may be an appendicitis

A, Press deeply and gently into the abdomen

B, Rapidly withdraw the hands and fingers

Inspiratory Arrest (Murphys Sign)

Normally, palpating the liver causes no pain. Hold your fingers under the liver border. Ask the person to take a deep breath. A normal response is to complete the deep breath without pain Positive Test - as the descending liver Positive test pushes the inflamed gallbladder into indicates: the examining hand, the person feels sharp pain and abruptly stops Cholecystitis inspiration midway inflammation of the gallbladder

Psoas Muscle Test

Perform this test when you suspect the acute abdominal pain is due to appendicitis. With the person supine, lift the RIGHT leg straight up, flexing the hip; then push down over the lower part of the right thigh as the person tries to hold the leg up. Negative test - the person feels no change When the psoas muscle is inflamed (due to perforated appendix), the pain is felt in the right lower quadrant.

Ascites
Fluid accumulation in the abdomen was recognized in ancient times. One of the most famous patients to receive large volume paracentises was Ludwig van Beethoven in 1827, whose physician wrote about his deathbed with the following description: "'the tremendous volume of the water accumulated called for immediate relief; and I found myself compelled to advocate the abdominal puncture in order to preclude the danger of sudden bursting.' Beethoven had almost immediate relief, and when he saw the stream of water, cried out that the operation made him think of Moses, who struck the rock with his staff and made the water gush forth. " Two days later Beethoven died. At autopsy his liver was described as "shrunken to half its normal volumeit was beset with knots the size of a beanthe spleen was double its proper size and dark colored and firm."

Ascites
Abnormal (pathologic) build up of fluid in the peritoneal (abdominal) cavity. Normally there should be almost no fluid here (i.e., surrounding the intestines and organs such as the liver and spleen). Ascites occurs because of one of three general problems: Peritonitis - Disease in the peritoneal cavity that is producing excessive fluid (e.g., infections or cancer) Portal hypertension- Fluid back up from the liver or large blood vessels into the peritoneal cavity Cirrhosis Hypoproteinemia - Low protein state in the body

Special Procedures for Ascites

Tests for ascites
Bulging Flanks Shifting dullness Fluid Wave

Bulging Flanks Inspection

Patient supine, the examiner visually observes whether the flanks are pushed outward (presumably by large amounts of ascitic fluid) Positive test: simply the presence of bulging flanks Note: A patient with an obese abdomen may also have flanks that bulge, although the fat of obesity extends further posterior than fluid in the peritoneum.

Shifting Dullness

Shifting Dullness (Supine Position) Percussion

The patient is examined in the supine position. Direct percussion is done over the abdomen, from the umbilicus to the flanks. The location of the transition from tympany to dullness is noted. Positive test:
Percussion note is tympanitic over the umbilicus Dull over the lateral abdomen and flank areas

Note: The tympany over the umbilicus occurs in ascites because bowel floats to the top of the abdominal fluid at the level of the fluid meniscus.

Percussion Pattern for Ascites.

Shifting Dullness (Side Position)

Patient then is rolled on his/her side away from the examiner, and percussion from the umbilicus to flank area is repeated. Positive test:
If ascites is present, the area of dullness will shift to the dependent site. The area of tympany will shift toward the top.

Note: The shift in zone of tympany with position change will usually be at least 3 cm when ascites is present.

Testing for Shifting Dullness Dullness Shifts to the Dependent Side

Fluid Wave
Have the patient lying supine. Patient places one or both hands (ulnar surface of hand downward) in a wedge-like position into the patient's mid abdomen, applying with slight pressure. Examiner places the fingertips of one hand along one flank, and with the other hand firmly gives a sharp tap along the opposite flank. Positive test:
Examiner detects "a shock wave" of fluid moving against the fingertips pressed along the flank, as the fluid is pushed from one side of the abdomen to the other by the force of the tap along the opposite flank.

Percuss the Kidneys

Costovertebral Angle Tenderness Indirect Percussion

Abnormal Abdominal Sounds

Hypo- and hyperactive bowel sounds
Vascular sounds of bruits and venous hums

Friction rubs

Abnormal Abdominal Sounds

Hypoactive Bowel Sounds

Decreased Motility Peritonitis, Paralytic Ileus

Hyperactive Bowel Sounds (Borborygmi)

Mechanical Obstruction, Gastroenteritis

Abdominal Friction Rubs and Vascular Sounds

Spleen abscess, tumor

Liver abscess or malignancy

Aortic Aneurysm

Artery Stenosis

Abdominal Pain
Direct vs Referred

Pain in Common Abdominal Disorders

Sites of Referred Pain

Abnormal Abdominal Findings

Abdominal distention Hernia

Abdominal Distention
Mnemonics - The 9- Fs of Abdominal Distention

Fat (obesity) Fluid (ascites) Feces Fetus (Pregnancy) Flatus (gas) Fibroid Full bladder False pregnancy Fatal tumor

Obesity
o Distention or protuberance of the abdomen o Caused by a thickened abdominal wall and fat deposited in the mesentery and omentum o Percussion produces:
o Normal tympanic sounds

Gaseous Distention
Tympany heard over a large area Results of increased of gas in the intestines Occurs with some foods and is associated with altered peristalsis Seen in paralytic ileus and intestinal obstruction Percussion produces:
Tympany heard over a large area

Abdominal Tumor - Percussion is dull

Percussion is dull. This type of distention common in ovarian cyst and uterine tumor

Ascites

Ascites is the accumulation of fluid in the abdomen

Ovarian Cyst (Large)

Pregnancy - Single Curve, Umbilicus Protruding

Abdominal Hernias

Umbilical Ventral Hiatal

Umbilical Hernia

Ventral (Incisional) Hernia

Hiatal Hernia

Rolling Hiatal Hernia

Now on to specific diseases .