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Making sense of abdominalassessment By Mary C. O’Laughlen, RN, FNP-BC, PhDAssistant Professor • University of Virginia School of Nursing • Charlottesville, Va.

With abdominal assessment, you inspectfirst, then auscultate, percuss, and palpate.This order is different from the rest of thebody systems, for which you inspect, thenpercuss, palpate, and auscultate. The differ-ence is based on the fact that physical han-dling of peritoneal contents may alter thefrequency of bowel sounds.

What do you need to know about inspec-tion, auscultation, percussion, and palpationof the abdomen? In this article, I’ll help youmake sense of abdominal assessment.

InspectionFirst, take a look at the abdomen. You domost of the exam standing to the right ofyour supine patient. The abdomen is dividedinto four quadrants by drawing an imagi-nary vertical line down the middle of thesternum and a horizontal line through theumbilicus (see Abdominal quadrants and theirstructures).

Inspect for symmetry while standing atthe side of your patient, then move to a posi-tion behind his head. Note the contour of theabdomen: Is it flat, scaphoid (concave), orprotuberant (convex)? A flat contour isexpected in well-muscled, athletic adults;thin adults may have a scaphoid abdomen.A rounded abdomen is commonly seen inyoung children, but in adults it’s the resultof poor muscle tone from inadequate exerciseor being overweight. A localized enlarge-ment may indicate a hernia, tumor, cysts,bowel obstruction, or enlargement ofabdominal organs. Ask your patient to take adeep breath and hold it because this lowersthe diaphragm and compresses the organsof the abdominal cavity, which may makepreviously unseen bulges or masses appear.

To assess the abdomen for herniation ordiastasis recti (the separation of the rectus

abdominis muscles often caused by pregnan-cy or obesity), or to differentiate a mass inthe abdominal wall from one below it, askyour patient to raise his head. A bulge seenin the abdomen is a common symptom of ahernia. Abdominal hernias are caused by acombination of muscle weakness and strainthat produces an opening in the abdominalmusculature through which the abdominalcontents move.

Next, inspect the abdomen for changes inpigmentation and color of the skin. Cullen’ssign, a bluish color at the umbilicus, is asign of bleeding in the peritoneum. GreyTurner’s sign is bruising on the flanksindicating retroperitoneal bleeding, such asin pancreatitis. Jaundice is usually causedby liver disease or biliary tract obstruction.

Scars should be correlated with thepatient’s recollection of previous opera-tions or injuries. An injury that caused a vis-ible scar may have also caused adhesions(internal scarring) that may cause intestinalobstruction. Striae (stretch marks) on theabdomen may be a sign of past weightchanges or pregnancy. Cushing’s diseasemay cause purple striae. Also inspect for anylesions or nodules. They may or may not berelated to gastrointestinal diseases. Forexample, an enlarged umbilical node maysignal metastatic cancer. Liver disease maycause spider angiomas (spiderlike blood ves-sels that develop on the skin) or caputmedusae (dilated superficial veins radiatingfrom the umbilicus).

Peristalsis is the rhythmic contraction ofsmooth muscles to propel contents throughthe digestive tract that may be seen as arippling movement across a section of theabdomen. However, peristaltic movementisn’t normally seen on the surface of theabdomen. Visible peristalsis is usually

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Abdominal quadrants and their structuresThe abdomen can be divided into four areas: the right upper quadrant (RUQ), left upper quadrant (LUQ), right lower quadrant(RLQ), and left lower quadrant (LLQ).

RUQ■ Right lobe of the liver■ Gallbladder■ Pylorus■ Duodenum■ Head of the pancreas■ Hepatic flexure of the colon■ Portions of the transverseand ascending colon

RLQ■ Cecum and appendix■ Portion of the ascendingcolon

LUQ■ Left lobe of the liver■ Spleen■ Stomach■ Body and tail of thepancreas■ Splenic flexure of the colon■ Portions of the transverseand descending colon

LLQ■ Sigmoid colon■ Portion of the descendingcolon

Imagine theorgans in eachquadrant, asshown here.

abnormal and may be a sign of an intestinalobstruction. Pulsation in the upper midlineis often visible in thin adults. Marked pulsa-tions may be the result of increased pulsepressure or an abdominal aortic aneurysm.

AuscultationNormal gut sounds are gurgling sounds(usually occurring 5 to 35 per minute) thatcan be heard with the diaphragm of astethoscope. Decreased sounds, such as nosounds for 1 minute, are a sign of decreased

gut activity. Gut sounds may be markedlydecreased after abdominal surgery, abdomi-nal infection, or injury. Absent sounds (nosounds for 5 minutes) are an ominous sign.They can be caused by intestinal obstruc-tion, intestinal perforation, or intestinalischemia or infarction. See What’s thatsound? for other sounds you may hear.

PercussionPercussing the body gives one of threeresults:

• Tympany is usually present in most ofthe abdomen caused by air in the gut (ahigher pitch than the lungs).• Resonance is a lower-pitched and hollowsound (found in normal lungs).• Dullness is a flat sound without echoes;the liver, spleen, and fluid in the peritoneum(ascites) give a dull note, but an unusualdullness may be a clue to an underlyingabdominal mass.

With your patient supine, percuss all fourquadrants of the abdomen using proper tech-nique. Hyperextend the middle finger of yournondominant hand and place this finger firm-ly against your patient’s abdomen. With theend (not the pad) of your dominant middlefinger, use a quick flick of your wrist to strikethe finger on the abdomen. Categorize whatyou hear as tympanitic or dull.

You shouldn’t be able to percuss the blad-der unless it’s distended above the symph-ysis pubis. Use percussion to check fordullness and to determine how high thebladder rises above the symphysis pubis.

To percuss the liver, begin at the rightmidclavicular line over an area of tympany,moving to an area of dullness. Percussupward along the midclavicular line fromthe level of the umbilicus to determine thelower border of the liver; the area of liverdullness is usually heard at the costal marginor slightly below it. A lower liver border

that’s greater than 3 cm below the costalmargin may indicate organ enlargement.To determine the upper border of the liver,begin percussion on the right midclavicularline at an area of lung resonance and contin-ue downward until the percussion tonechanges to one of dullness; this marks theupper border of the liver. The usual spanof the liver is approximately 6 to 12 cm.A vertical span greater than this may indi-cate liver enlargement; a lesser span sug-gests atrophy. The liver is proportionateto the height and weight of your patient.

Percuss the spleen at the lowest costalinterspace in the left anterior axillary line.This area is normally tympanitic. Ask your

patient to take a deep breath and percussagain. Dullness with full inspiration maybe a sign of an enlarged spleen orsplenomegaly.

To percuss the kidneys, have yourpatient sit up on the exam table, place thepalm of your nondominant hand over theright costovertebral angle, make a fist withyour dominant hand, and use the ulnarsurface to strike your nondominant hand.Repeat the maneuver over the left costover-tebral angle. Compare the left and rightsides. Costovertebral angle tenderness isoften associated with renal disease, but

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What’s that sound?Use the diaphragm of your stethoscope to listen for these sounds.• Borborygmi (BOR-boh-RIG-mee) are normal, loud, and easily audiblesounds. • High-pitched, tinkling sounds are a sign of early intestinal obstruction. • A friction rub is a high-pitched sound heard in association with respira-tion. Although friction rubs in the abdomen are rare, they indicate inflam-mation of the peritoneal surface of the organ from tumor, infection, orinfarct. Listen for them over the liver and spleen.

Use the bell of your stethoscope to listen for these sounds.• Aortic bruits are heard in the epigastrium. They may be a sign ofabdominal aortic aneurysm.• Renal artery bruits are heard in each upper quadrant. They may be a signof renal artery stenosis, which is a potentially treatable cause of hypertension.• Iliac/femoral bruits are in the lower quadrants. They may be a sign ofperipheral atherosclerosis. • A venous hum is a soft, low-pitched, continuous sound heard in theepigastric region and around the umbilicus. It occurs with increased collat-eral circulation between the portal and systemic venous systems.

could be muscular in origin. You may wantto percuss the kidneys later in the exam soas not to tire your patient.

PalpationWith your patient in the supine position,begin light palpation by depressing the ab-dominal wall no more than 1 cm. At thispoint, you’re mostly looking for areas oftenderness. The most sensitive indicatorsof tenderness are your patient’s facial ex-pression. Also note any abdominal guard-ing that’s present. Next, proceed to deeppalpation, depressing 3.8 to 5 cm in an ef-fort to identify abdominal masses or areasof deep tenderness. If your patient is tick-lish, place your hand over his hand whilepalpating.

Palpate the liver by placing your left handunder your patient and your right hand lat-eral to the rectus muscle, with your finger-tips below the liver border. Because the livermoves down on inspiration, press gently inand up as your patient takes a deep breath.The liver is considered enlarged if the edgeextends more than 2 cm below the rightcostal margin. If your patient is obese, usethe hooking technique. Stand by his chest,hook your fingers just below the costal mar-gin, and press firmly. Ask him to take a deepbreath. You may feel the edge of the liverpress against your fingers as it descends oninspiration.

When palpating the spleen, stand on yourpatient’s right side and reach over, usingyour left hand to lift his left lower rib cageand flank. Press down just below the leftcostal margin with your right hand and askhim to take a deep breath. If enlarged, thespleen will come down on inspiration and

you’ll feel the tip. The spleen isn’t normallypalpable on most individuals.

To palpate the left kidney, stand on yourpatient’s right side and reach across with yourleft hand. Place that hand over the left flankand your right hand at your patient’s leftcostal margin. Have him take a deep breath,elevate the left flank with your left hand, andpalpate deeply (because of the retroperitonealposition of the kidney) with your right hand.Kidneys move down with inspiration, so tryto feel the lower edge of the kidney whenyour patient inhales. The left kidney is ordi-narily not palpable unless enlarged.

To palpate the right kidney, place onehand under your patient’s right flank andthe other hand at the right costal margin.Because of the anatomic position of theright kidney (lower because of beingpushed down by the liver), it’s more easilypalpable than the left kidney. If it’s palpable,it should be smooth, firm, and nontender.

The importance ofassessmentPerforming an abdominal assessment willhelp you detect health problems in your pa-tients earlier and prevent further complica-tions from developing with existing disease.And now you’ve learned how to do a thor-ough physical assessment of the abdomenand the importance of systematically docu-menting your findings. ■

Learn more about itBickeley LS, Szilagyi PG. Bates’ Guide to Physical Examina-tion and History Taking. 10th ed. Philadelphia, Pa., Lippin-cott Williams & Wilkins; 2008: 434-451.

Health Assessment Made Incredibly Visual! Philadelphia, PA,Lippincott Williams & Wilkins; 2007:132-139.

University of Washington. Techniques: Liver and ascites.http://depts.washington.edu/physdx/liver/tech.html.

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