Abdominal AssessmentNUR 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

Solid VisceraMaintain a characteristic shape

• Liver• Spleen• Pancreas• Adrenal glands• Kidneys• Uterus• Ovaries

Hollow VisceraShape 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 structuresVisceralParietal

Abdominal Vasculature and Deep Structures.

Aorta

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 LUQ RLQ 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 DataHealth History Questions

• Appetite (weight gain or weight loss)

• Dysphagia

• Food intolerance

• Abdominal pain

• Nausea/vomiting (medications, GI disease)

• Bowel habits

• Past abdominal history

• 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

• 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

Inspect the Abdomen

Contour of the Abdomen

Flat

Contour of the Abdomen

Rounded (convex)

Contour of the AbdomenScaphoid (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

Fully rounded or distended, umbilicus everted Distended lower third

Fully rounded or distended, umbilicus inverted Distended lower half

Fully rounded or distended, umbilicus everted Distended lower third

Scaphoid Distended upper half

Umbilical Hernia

Striae “Stretch Marks”

Usually Seen in Obesity, Pregnancy, and Ascites

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

Caput Medusae Dilated Venous Pattern Over the

Right Upper Abdomen

Linea NigraThird Trimester of

Pregnancy

Spider Angiomata Most Commonly on the Trunk and

Upper Extremities

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, high-

pitched, gurgling sounds occurring 5-30 per minute

– Don’t 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

Sites to Auscultate for Bruits: Aorta, Renal Arteries, Iliac Arteries, and Femoral

Arteries

Vascular Sounds Use Bell of Stethoscope

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:TympanyDullnessHyperresonance

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

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

ResonanceResonanceDullness

DullnessTympanyTympanyTympany

TechniquePercussion 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 TestTo 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 cm’s it extends below the left costal margin.

PALPATION

Palpation of Abdomen

• Measures to enhance muscle relaxation

• Palpate abdomen– Light palpation

– Deep palpation

– Bimanual palpation

• Liver– Usual technique

– Hooking technique

• Spleen

• Kidneys

• Aorta

• Special procedures– Rebound tenderness

(Blumberg sign)

– Inspiratory arrest (Murphy’s sign)

– Psoas muscle test

PalpationLight/Deep/Bimanual

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 the LiverPalpate 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

Ask client to take a deep breath

Normally, the liver is not palpable, except in thin clients

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.

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 person’s 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 SpleenTechnique

• 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

– Blumberg’s 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

(Blumberg’s Sign)

• Position the patient supine• Place your hands gently on the RLQ at

McBurney’s 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 Burney’s point” Halfway between

umbilicus and right iliiac crest

Rebound Tenderness (Blumberg’s Sign)

A, Press deeply and gently into the abdomen B, Rapidly withdraw the hands and fingers

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

Inspiratory Arrest (Murphy’s 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 pushes the inflamed gallbladder into the examining hand, the person feels sharp pain and abruptly stops inspiration midway

Positive test indicates:

Cholecystitis - 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 volume…it was beset with knots the size of a bean…the 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 FlanksInspection

• 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 Rubsand Vascular Sounds

Aortic Aneurysm

Artery Stenosis

Liver abscess ormalignancy

Spleen – abscess, tumor

Abdominal PainDirect vs Referred

Pain in Common Abdominal Disorders

Sites of Referred Pain

Abnormal Abdominal Findings

• Abdominal distention

• Hernia

Abdominal DistentionMnemonics - 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 DistentionTympany 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 …….