Abdomen

Assessment of the Abdomen

Patricia Jackson AllenRN, MS, PNP, FAAN

Yale University, School of Nursing

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 eachquadrant, 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


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


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


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

Illnesses / infectious diseaseIllnesses / infectious disease

Past Medical History

– Acute GI infections– Hepatitis– PID, STI’s– HIV– UTI’s– Diverticulitis– Ulcers

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

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


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 “F’s”: 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 ofContour 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


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

RespirationsAbdominal 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


Decreased bowel sounds Total obstruction Paralytic ileus Peritonitis Severe ascites

Absence of bowel sounds established after 5 minutes of listening


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 Percussionfor Liver Inflammation

Bimanual Percussionfor 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 organsMass descriptors

Location Size Shape Consistency Tenderness Pulsation Mobility

Light palpation Deep palpation

Structures CommonlyPalpated as Masses


Areas of cutaneous sensitivity


Liver Normally palpable near right costal margin, mid-

clavicular line. Palpate with right hand starting below umbilicus

and moving upward until liver palpable. Remember the liver is a superficial organ.

Liver Palpation

Finger TipsSide of Hand


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


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


Stool Firm, movable, mildly tender, elongated mass

often palpable in sigmoid colon


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 Murphy’s 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 pressingdown on lower thigh. Lower quadrant pain may indicate appendicitis.

Murphy’s 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 AbnormalAbdominal 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

Abdomen

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