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Assessment of the Abdomen

Patricia Jackson Allen


RN, MS, PNP, FAAN

Yale University, School of Nursing

Abdominal Structures

Abdominal Structures

Abdominal Structures

Abdominal Structures

Abdomen Mapping
Anatomical landmarks
Xiphoid process Costal margins Iliac crest Anterior superior iliac spine Symphysis pubis Umbilicus

Four Quadrants of Abdomen


When examining each quadrant, remember what organs and structures are found found in each quadrant

Four Quadrants of the Abdomen


Right Upper Quadrant
Liver Pylorus valve of stomach Duodenum Right kidney and adrenal gland Hepatic flexure of colon Portions of ascending and transverse colon

Four Quadrants of the Abdomen


Right Lower Quadrant
Appendix and cecum Ascending colon Bladder if distended Ovary Uterus if enlarged Right spermatic cord Right ureter

Four Quadrants of the Abdomen


Left Upper Quadrant
Tip of medial lobe of liver Spleen Stomach Left kidney and adrenal gland Pancreas Splenic flexure of colon Portions of transverse and descending colon

Four Quadrants of the Abdomen


Left Lower Quadrant
Sigmoid colon Descending colon Bladder if distended Ovary Uterus if enlarged Left spermatic cord Left ureter

History
Chief complaint / present illness
Abdominal pain Indigestion Nausea Vomiting Diarrhea Constipation

History
Chief complaint / present illness
Fecal incontinence Jaundice Dysuria Urinary frequency Urinary incontinence Hematuria, blood in stool Weight loss, weight gain

History
Symptom characteristics
Onset and duration Getting better or worse Character or quality Associated symptoms Location, radiation

History
Symptom characteristics
Factors that relieve or exacerbate symptoms Alterations in activities of daily living Others in family with similar symptoms Home or prescribed treatment Prior evaluation or treatment

Past Medical History


Perinatal history
Pregnancies, abortions, miscarriages Birth defects Infant feeding problems Prematurity Short bowel syndrome

Past Medical History


x Illnesses

/ infectious disease
Gallbladder illness Colitis Cystic fibrosis Food allergies / intolerance Constipation GERD Irritable bowel

Acute GI infections Hepatitis PID, STIs HIV UTIs Diverticulitis Ulcers

Past Medical History


Immunizations
Hepatitis B Hepatitis A Cholera Typhoid Rota virus Other

Past Medical History


Laboratory test
Stool cultures Abdominal x-ray, sonograms, ultrasounds Urinalysis H. pylori tests Ova and parasites Sigmoid or colonoscopy Organ biopsy

Past Medical History


Operations / hospitalizations / ER visits
Abdominal surgery Appendicitis Trauma to abdomen Births Blood transfusions Acute gastroenteritis (AGE) Organ inflammation (liver, pancreas, gallbladder) Recurrent abdominal pain

Past Medical History


Accidents (unintentional injury)
Car Bike Skateboard Falls

Past Medical History


Medication use
Antibiotics Laxatives Suppositories, enemas Antacids Ulcer medications Iron and vitamins Chronic steroid or ASA use Birth control Folk remedies

Family History
Infectious conditions (hepatitis, AGE) Constipation, irritable bowel Ulcers, diverticulitis, inflammatory bowel Gallbladder disease Symptoms similar to CC Colon cancer, ovarian cancer Ova and parasites

Personal and Social History


Nutrition Last menstrual period Sexual practices and protection Substance use, including caffeine, alcohol, tobacco Recent stress Weight gain or loss Anorexia, bulimia, dieting Travel outside of country

Preparation for Abdominal Examination


Have child empty bladder Have child lie supine with hips and knees flexed Drape for privacy Tell child what you will do before you do it Have warm room and warm hands Have good light source Examine identified painful areas last

Position for Abdominal Examination

Correct

Incorrect

Drape for Modesty

Assessment of the Abdomen


Inspection Auscultation Percussion Palpation

Assessment of the Abdomen


Inspection
Skin
Scars Striae Dilated veins, vein pattern Rashes Lesions

Assessment of the Abdomen


Inspection
Umbilicus
Location Contour Signs of inflammation or bulging

Contour
Symmetrical / asymmetrical Flat Rounded Protuberant Scaphoid

Causes of Abdominal Distention


Obesity Pregnancy Tympanitis Ascites Feces Neoplasms

(Six Fs: Fat, Fluid, Flatus, Fetus, Fecus, Fatal growths)

Location of Distention
Xiphoid Umbilicus Pubis Midline Diaphragmatic hernia Umbilical hernia Pregnancy, distended bladder Diastasis recti

Midline Contour Variation

Diastasis Recti

Normal Variations of Contour with Age


Infant-toddler
Protuberant

Preschool age child


Rounded, lumbar lordosis

School age child


Scaphoid

Adolescent / adult
Varied

Infant Abdomen

Toddler / Preschooler Abdomen

School-Age Abdomen

Assessment of the Abdomen


Inspection
Peristalsis
May be seen in thin individuals or with obstructive conditions

Pulsation
Pulsations of descending aorta may be seen in thin individuals

Assessment of the Abdomen


Inspections
Respirations
Abdominal breathing normal until school age
Intercostal breathing occurs with Respiratory distress Abdominal inflammation Pneumonia or pleural effusion may cause Abdominal pain Altered respirations

Assessment of the Abdomen


Auscultation
Bowel sounds Vascular sounds Organ size, location

Warm stethoscope before use

Assessment of the Abdomen


Auscultation
Increased bowel sounds
Diarrhea Colic Malrotation Intussusception Diverticulitis

Assessment of the Abdomen


Auscultation
Decreased bowel sounds
Total obstruction Paralytic ileus Peritonitis Severe ascites

Absence of bowel sounds established after 5 minutes of listening

Assessment of the Abdomen


Auscultation
Scratch test for liver size
Intensity of sound increases as you approach liver edge

Abdominal Auscultation for Bruits

Techniques for Relaxation of Children for Percussion and Palpation


Pacifier to encourage relaxation with sucking Flex knees and hips Distraction, support of caregiver Reassure procedure will not hurt Involve them in procedure Use of puppets or toys

Assessment of the Abdomen


Percussion
Percussion is excellent for assessing organ size, presence of masses, fluid or gas. Tympany stomach, bowel Resonance bowel Dullness liver Flat thigh

Percussion
Tympany
High pitch note elicited over airfilled structures, such as viscera and stomach.

Dull
Short high-pitched sound with little resonance. Found in solid or fluid filled organs adjacent to air containing organs, i.e., liver, spleen, distended bladder.

Flat
Very short, high-pitched sound produced over tissue which contains no air, i.e., muscle, large solid mass.

Assessment of the Abdomen


Percuss
4 quadrants for gas or masses Liver span Spleen size Costovertebral angle (CVA) tenderness

Abdominal Percussion

Assessment of the Abdomen


Liver percussion
At right mid-clavicular line, start below umbilicus and percuss upward until dullness of sound heard Liver usually @ right costal margin +/- 2 cm Size and shape of liver vary

Liver Percussion

Assessment of the Abdomen


Spleen Percussion
Splenic dullness may be heard near left 10th rib posterior to the mid-axillary line
Usually not found unless enlarged Obscured by air in the colon

Percuss at 10th intercostal space to determine dullness with deep breath

Percussion of Spleen

Percussion of the Spleen

Assessment of the Abdomen


Percussion for tenderness of liver or kidneys
Place palm of one hand over organ. Strike hand with ulnar surface of other hand. If organ is inflamed, this will result in pain.

Bimanual Percussion for Liver Inflammation

Bimanual Percussion for Kidney Inflammation

Assessment of the Abdomen


Palpation
Light palpation
Assessment of skin turgor Muscle tone Superficial lesions or masses Areas of tenderness

Assessment of the Abdomen


Deep palpation
Assess for masses or enlarged organs Mass descriptors
Location Size Shape Consistency Tenderness Pulsation Mobility

Light palpation

Deep palpation

Structures Commonly Palpated as Masses

Assessment of the Abdomen


Palpation
Areas of cutaneous sensitivity

Assessment of the Abdomen


Palpation
Liver
Normally palpable near right costal margin, midclavicular line. Palpate with right hand starting below umbilicus and moving upward until liver palpable. Remember the liver is a superficial organ.

Liver Palpation

Finger Tips Side of Hand

Assessment of the Abdomen


Palpation
Spleen
Difficult to palpate unless enlarged Deep palpation under L costal margin at the anterior axillary line
Will descend with deep inspiration Can roll person to R side to move spleen towards midline

Spleen Palpation

Spleen Palpation

Assessment of the Abdomen


Palpation
Kidneys
Difficult to palpate unless enlarged With hands perpendicular to midline between rib cage and iliac crest, press hands gently but firmly together. Have person take deep breath. May feel kidney slide between hands. Right kidney normally lower than left kidney.

Kidney Palpation

Assessment of the Abdomen


Palpation
Stool
Firm, movable, mildly tender, elongated mass often palpable in sigmoid colon

Assessment of the Abdomen


Palpation
Bladder
If distended, bladder is palpable midline above symphysis pubis Smooth round mass, not moveable

Assessment of the Abdomen


Special maneuvers
Rebound tenderness Psoas maneuver Obturator sign Murphys sign

Rebound Tenderness at McBurney Point

Sharp pain when pressure released in RLQ suggest appendicitis

Obturator Muscle Test

Flex R leg at hip & knee. Rotate leg laterally & medially. Pain in hypogastric region may indicate ruptured appendix

Iliopsoas Muscle Test

Ask to raise the R leg flexing at the hip while pressing down on lower thigh. Lower quadrant pain may indicate appendicitis.

Murphys Sign
Client complains of sharp pain when trying to take a deep breath while examiner performs deep palpation in URQ. Inflamed gallbladder descends during inspiration resulting in pain

Abdominal Signs of Abuse

Common Abnormal Abdominal Findings

Hernias
Protrusions of the peritoneum or intestine through a weakened spot in musculature of abdominal wall. Umbilical hernias rarely need intervention. Inguinal and femoral hernias are usually surgically corrected.

Umbilical Hernia

Hernia

Inguinal & Femoral Hernias

Hernias
Inspection
Assess for bulges with crying or bearing down.

Auscultation
Assess for hums or bruits - should not be present. May hear bowel sounds.

Hernias
Percussion
Can not percuss hernia.

Palpation
Mass soft, nontender and retractable. Measure opening in musculature with finger tips.

Pyloric Stenosis
Hypertrophy of the pyloric valve prevents feed from leaving the stomach. Infant initially feeds well but then develops persistent vomiting.

Pyloric Stenosis
Inspection
Peristalic wave over stomach area Projectile vomiting

Auscultation
Hyperactive sounds over stomach area Hyperactive sounds over intestines

Pyloric Stenosis
Percussion
Resonant stomach sounds. Contents expelled.

Palpation
An enlarged, firm, olive shape mass may be palpable in RUQ. Needs to be referred to MD for ultrasound testing and then surgery.

Appendicitis
Appendicitis is the most common cause of acute surgical abdomen in childhood.
Rare in early childhood, becoming more frequent after age 10. History includes dull aching, steady peri-umbilical pain that localizes to RLQ after 4-6 hours. Nausea and vomiting frequently occur but there is no change in bowel habits. Low grade fever may be present.

Appendicitis
Inspection
Note guarding or pain with walking or coughing. Abdominal distention may be present. Prefer supine position with knees flexed.

Auscultation
Bowel sounds may be decreased or hyperactive. Need to auscultate RLL of lungs carefully to rule out lobar pneumonia with referred pain.

Appendicitis
Percussion
Increased tenderness may make percussion too uncomfortable to perform.

Palpation
Tenderness over area of inflamed appendix, usually RLQ (McBurney point). Rebound tenderness localized to same area. Unable to palpate inflamed appendix. Rectal exam usually finds right-sided tenderness.

Abdominal Pain

Abdominal Pain
Inspection
Limitation of movement or alterations in breathing pattern (shallow or chest breathing) are important assessment criteria. Watch client climb on or off the exam table Periumbilical pain less likely to be serious than other locations Evaluate for weight loss or gain

Abdominal Pain
Auscultation
Bowel sounds may be increased or decreased Friction rub may be heard with pleural inflammation or peritoneal inflammation

Percussion
Percussion over areas of inflammation may result in pain Watch facial expressions as you attempt to distract individual. Those who watch you have more pain.

Abdominal Pain
Palpation
Palpation may identify localized or generalized pain. Watch facial expressions as you attempt to distract during palpation. Firm but gentle palpation is best.

Pregnancy
Inspection
Enlargement of lower abdomen, midline Enlargement of breast Linea nigra, increase facial pigmentation, striae

Auscultation
Fetal heart sounds

Pregnant Abdomen

Pregnancy
Percussion
Dull mass in lower abdomen Displaced tympany of bowel and stomach

Palpation
Fetal outline Fundus of uterus