PHYSICAL ASSESSMENT OF THE ABDOMEN

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PHYSICAL ASSESSMENT OF THE ABDOMEN

• Dr. Beverly Fineman
• Nursing 309

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OBJECTIVES

• At the end of this class, the student will be
  able to
• Identify landmarks for the abdominal assessment
• Correctly perform techniques of inspection,
  auscultation, percussion and palpation
• Differentiate normal from abnormal findings
• Document findings

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Overview of abdominal structure.

• large oval cavity
• extends from diaphragm to symphysis
• viscera solid and hollow

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Landmarks for the abdominal examination

• four quadrants
• nine sections
• bony landmarks
• muscles

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More landmarks

• Bony landmarks on the anterior body include
• xiphoid process of sternum
• costal margin, midline, umbilicus, anterior
  iliac spine, pouparts ligament, superior margin
  of pubis
• Posterior landmark
• costovertebral angle

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Abdominal assessment

• Preparing the exam room
• preparing the patient
• positioning the examiner

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Assessment Techniques

• inspection
• skin color, scars, veins, lesions, umbilicus
• umbilical hernia, bleeding, inflammation

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Continued inspection

• contour of the abdomenflat,rounded,
  protuberant,scaphoid
• symmetry
• enlarged organ
• masses
• peristalsis,pulsation,distention

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distention

• -Definition
  unusual stretching of
• 
  abdominal wall
• note position of umbilicus
• note portion of abdomen that is
• distended
• reasons for distentionflat(obesity),
• flatus(gas), feces, fluid,
• fetus(pregnancy or tumor)

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Auscultation

• Where it occurs in abdominal assessment
• listening for bowel sounds to assess motility
• normal sounds
• abnormal sounds
• how and where to listen

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Auscultation continued

• Auscultation performed before
• palpation and percussion
• Use diaphragm of stethoscope
• Listen to bowel sounds
• Normal sounds are clicks and
• gurgles, irregular, 5-30 times per minute
• Influenced by digestion

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More on Auscultation

• Increased bowel sounds are due to hypermotility
  of peristalsis
• Decreased are due to paralytic ileus or
  peritonitis
• intestinal obstruction can present with
  increased or decreased sounds

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Additional Sounds

• Always listen in hypertensive patient
• Bruits
• Bruits are low pitched, vascular sounds,
  resembling murmur
• Caused by partially obstructed artery turbulence
• Listen in epigastrum and each upper quadrant
• Listen in costovertebral angle(with patient
  seated)
• Listen over aorta, iliac arteries, femoral
  arteries
• Arterial insufficiency in legs

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PERCUSSION

• Assessment technique used to assess size and
  density of organs in the abdomen
• Examples used to measure size of liver or spleen

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More on percussion

• Used to identify masses
• Used to identify air in stomach or in bowel
• Used alone or in conjunction with palpation or to
  validate palpatory findings
• Orient yourself to the abdomen by lightly
  percussing all 4 quadrants for tympany or
  dullness
• tympany usually predominates due to gas in
  the bowel

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Percussion Continued

• Dullness may be present due to feces or fluid or
  over organs or a solid mass
• Develop a specific percussion route and stick to
  it.
• To percuss the liver or estimate its size
• in right midclavicular line, start below the
  umbilicus with tympany and percuss
  upward toward liver dullness.
• Mark to indicate the liver border

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Liver Percussion

• In the right midclavicular line, percuss down
  from lung resonance to liver dullness. This
  indicates the lower border of the liver
• Mark this and measure between the two lines
• This is the height of the liver

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More about percussion

• Percussion provides most accurate clinical
  measurement of liver size as a gross measurement

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Percussing the spleen

• Where is the spleen located?
• in the curve of the diaphragm just posterior
  to the left midaxillary line
• When the spleen enlarges, it does so anteriorly,
  downward and medially. This will replace the
  tympany of the stomach and colon with dullness

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Tricks to Assessing the Spleen

• Percuss in the lowest interspace in the left
  anterior axillary line for tympany.
• Ask the patient to take a deep breath and percuss
  on inspiration.
• the percussion note should remain tympanic
• A change to dullness suggest spenomegally
• This is known as a positive splenic percussion
  sign

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Another trick

• Percuss in several directions away from
  tympany or resonance to dullness
• outline edges
• a large dull area suggests splenomegally

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Other Findings

• To differentiate amongst fat, gas, tumor or
  ascites
• fattympany with scattered areas of dullness
  
• gasdistention with tympany
• tumordullness with tympany
• ascitesfluid seeks the lowest point in the
  abdomen. Flanks are dull to percussion with
  tympanic center. There is a protuberant abdomen
  with bulging flanks

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Assessing for Ascites

• With patient lying supine, find tympany in center
  of abdomen
• From center of abdomen, percuss outward in
  several directions to denote dullness
• To test for shifting dullness, ask patient to
  turn to one side, then percuss from tympany to
  dullness
• fluid will sink to lowest point

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More on ascites

• Assess for fluid wave
• Puddle sign

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Assessing for kidney tenderness

• Find the costovertebral angle
• This is the angle formed by the lower border of
  the 12th rib and the transverve processes of the
  upper lumbar vertebrae
• Place left hand flat in this area on one side,
  hit the hand sharply with the fist of the other.
  Patient will admit to tenderness if present.
• Repeat on the other side

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PALPATION

• Used to assess muscle tone, tenderness, fluid,
  organs
• May be light or deep
• Use pads of fingertips in light dipping motions
  and avoid short jabs

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Palpation cont.

• To differentiate voluntary from involuntary
  resistance rectus muscle will relax with
  expiration.
• Palpation is light or deep
• Deep palpation used to define and delineate
  organs or abdominal masses.
• Use palmar surface of fingers and feel in all
  four quadrants

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Deep palpation

• If masses are felt, note location, size,
  shalpe, consistency, tenderness, pulsations,
  mobility with respiration or with hand.
• If patient is obese or rigid, use 2 hands to
  palpate
• Place one on top of other and feel with lower
  hand

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The bladder

• Bladder percussion is unnecessary unless there is
  a suspicion of urinary retention
• Palpate above the symphysis
• An empty bladder is not palpable

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Palpation of the liver

• Stand on patients right side
• Place left hand behind patient parallel to and
  supporting 11-12th ribs
• Patient should relax
• Press your left hand forward and place your right
  hand on abdomen with fingertips below lower edge
  liver dullness
• Press in and up while patient takes deep breath
  if palpable, liver should come down

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Palpation cont.

• Liver hook
• Kidney not palpable in normal adult
• May be able to feel lower right kidney pole in
  very thin person

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The spleen

• The spleen is usually not palpable
• From patients right side, reach over and around
  under patient with your left hand
• Place right hand below left costal margin and
  press in toward spleen. Ask patient to take deep
  breath---will feel if palpable

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Assessing for peritoneal irritation

• Ask patient to cough. Palpate lightly with one
  finger over area of pain produced by cough
• Test for REBOUND TENDERNESS press finger in
  firmly and slowly then quickly withdraw. Rebound
  tenderness mean the withdrawal has caused the
  pain--- not the pressure
• Other Psoas sign and Obturator sign, cutaneous
  hyperesthesia

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Assessing the Aorta

• Press firmly deep in upper abdomen slightly to
  left of midline.
• Feel for aortic pulsations
• Determine width of aorta by pressing deeply on
  either side of aorta
• What is the normal width of the aorta?
• If pulsatile mass is found, feel for femoral
  pulses which may be dimished.

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This concludes the examination of the abdomen
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Examination of the anus and rectum

• This information is sometimes included with the
  abdominal assessment and at times with assessment
  of the male and female genitalia.
• For our purposes, we are including it here

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General Principles

• Anal canal is outlet of GI tract
• 3.8cm long
• Merges with rectal mucosa _at_ anorectal junction
• Sensory nerves in anal area responsible for pain
  due to trauma

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Sphincters

• 2 concentric layers of muscle that keep anal
  canal closed
• Internal sphincter
• under involuntary control by autonomic
  nervous system
• External sphincter
• surround internal sphincters
• under voluntary control
• Intersphincteric groove palpable separation
  between internal and external sphincter

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MORE THAN YOU WANT TO KNOW

• Anal columns - -folds of mucosa extend vertically
  from rectum and end in anorectal junction
• Can be seen with scope
• Each column contains and artery and vein

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hemorrhoids

• With increased venous (portal) pressure, vein can
  enlarge.
• this is a hemorrhoid or a varicosity
• External hemorrhoids occur below the anorectal
  junction
• itch and bleed with defecation
• painful and swollen with thrombosis
• resolve and leave flabby skin top around
• anal opening.

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continued

• Internal hemorrhoids originate above anorectal
  junction
• covered with mucosa
• may appear as red mass with pressure
  (valsalva)