Islamic University of Gaza Faculty of Nursing Chapter (9) Assessment of the abdomen

Assessment of the abdomen -The largest body cavity *Subjective data: ask the client about: Nutritional history: appetite, weight loss or gain. Gastrointestinal symptoms: dysphagia, nausea, vomiting, and indigestion. Bowel habits: pattern, and stool characteristics. Pain: location, quality, pattern, and relationship to ingestion of food. Use of medications: Aspirin, anti inflammatory drugs, and steroids. Gastrointestinal diagnostic tests and surgeries.

Assessment of the abdomen cont.. The client is placed in the supine position, with small pillows under the head and knees. The abdomen is exposed from the breast to the symphysis pubis Assessment should start with inspection, auscultation, then percussion and palpation. Ask client to stand right side and carry out assessment systematically, beginning with the left upper quadrant. The bladder should be empty.

4 Quadrants

9 Regions

RIGHT UPPER QUADRANT LIVER GALLBLADDER DUODENUM HEAD OF PANCREAS RIGHT KIDNEY AND ADRENAL HEPATIC FLEXURE OF COLON PART OF ASCENDING AND TRANSVERSE COLON

LEFT UPPER QUADRANT STOMACH SPLEEN LEFT LOBE OF LIVER BODY OF PANCREAS LEFT KIDNEY AND ADRENAL SPLENIC FLEXURE OF COLON PARTS OF TRANSVERSE AND DESCENDING COLON

RIGHT LOWER QUADRANT CECUM APPENDIX RIGHT OVARY AND TUBE RIGHT URETER

LEFT LOWER QUADRANT PART OF DESCENDING COLON SIGMOID COLON LEFT OVARY AND TUBE LEFT URETER

Assessment of the abdomen cont.. *Inspection: Under source of light you see exactly changes in contours. Assess the presence or absence of symmetry, distention, masses, visible peristaltic waves and respiratory movement. Inspect the abdominal skin for pigmentation e.g. jaundice, lesions, striae scars, dehydration, general nutritional status and condition of umbilicus, this give information about general state of health.

Assessment of the abdomen cont.. Contour of the normal abdomen is described as: flat, rounded, or scaphoid. N.B: contour is description of the profile line from the rib margin to the pubic bone. Flat contour seen in the muscularly competent and well nourished individual. Rounded abdomen: Normally in infant and toddler, but in the adult caused by poor muscle tone and excessive Subcutaneous fat deposition. Scaphoid contour “Concave in horizontal line” seen in thin clients of all ages. Inspect for respiratory movements especially for retraction of the abdominal wall on inspiration which is called "Czerny's sign “associated with some Central Nervous System diseases such as chorea”

Assessment of the abdomen cont.. *Auscultation: -Auscultate peristaltic sounds which are normally high pitched. Listen for at least "5" minutes before concluding that no bowel sounds are present. "Peristaltic sounds may be quite irregular". Duration of single sound may be less than a second or more than it. Stimulation of peristalsis may be achieved by flicking the abdominal wall with a finger “direct percussion Auscultate vascular sounds: Loud bruits detected over the aorta may indicate presence of an aneurysm; the aorta is auscultated superior to the umbilicus.

Assessment of the abdomen cont.. Listen for Peritoneal friction rub over the area of liver and spleen e.g. spleen infection, abscess or tumor: best heard over the lower rib cage in the anterior axillary line. (rough grating sound like sound of two pieces of leather being rubbed together).

Assessment of the abdomen cont.. *Percussion: To detect fluid or gaseous distention and masses and assessing solid structures within the abdomen. Percussion of one for each quadrant to assess areas of tympany and dullness. Potentially painful areas are always percuss last. Percussion allows you to identify borders of the liver to detect organ enlargement.

To detect liver size, start percussion at the right iliac crest and proceeds up ward on the right mid-clavicular line, when dullness occur this is the lower border of the liver. To detect upper border of the liver percuss, down from the nipple along mid-clavicular line, then dullness occur “upper border” may be found in (5,6,7) intercostals space, distance between points lower and upper is (6-12cm). *N.B: Diseases e.g. cirrhosis, cancer, and hepatitis cause liver enlargement.

Midclavicular and axillary lines

Assessment of the abdomen cont.. *Stomach position: With percussion you can locate the tympanic air bubble of the stomach by percussing over the left lower anterior rib cage. * Kidney Tenderness: In sitting or erect position, use direct or indirect percussion to assess for kidney inflammation. Use ulnar surface of the partially closed fist and percuss the costo-vertebral angle at the scapular line. If the kidneys are inflamed, client feels tenderness during percussion

Assessment of the abdomen cont.. *Palpation: Detect abdominal tenderness and noting the quality of abnormal distensions or masses. During palpation assess for muscular resistance, distention, tenderness and superficial organs or masses. Assess for distended bladder if client has inability to void (bladder lies normally below the umbilicus and above symphysis pubis). In deep palpation depress hands (2.5-7.5 cm), "1-3 inch" **N.B: Deep palpation never used over a surgical incision or tender organs, or masses. If tenderness present, check for rebound tenderness, if it was positive indicated peritoneal irritation e.g. appendicitis

REBOUND TENDERNESS

Assessment of the abdomen cont.. *Liver: Right upper quadrant under the rib cage. Place your left hand under client’s posterior thorax at the 11th and 12th ribs and by your right hand palpate in and up to feel the liver’s edge as the client inhales. **G.B normally not felt and if distended it felt under liver and may indicate cholecystitis. *Spleen: Generally not palpable in normal adult person, but in case of spleen enlargement you can palpate it below costal margin.

PALPATION OF LIVER

PALPATION OF SPLEEN

*Rectus: * Assessment of the anus and recto sigmoid region, rectal exam is an important component of every comprehensive physical examination. -Events required rectal examination: Abdominal pain. Alternation in bowel habits. Anal pain, anal spasm. Anal itching or burning. Black tarry stool. Rectal bleeding.

* Positions for rectal examinations: Left lateral or Sims position. Knee- chest position. Standing position, most common use for prostate gland examination. Lithotomy position. Squatting position. **In all positions, before examination wear two gloves.

*Inspection: Spread buttocks carefully with both hands to examine the anus and skin around it which is more pigmented, moist, and hairless. Assess lesions, scars, or inflammation, peri-rectal abscess, fissures, piles, fistula opening, tumor and rectal prolapsed. Ask the client to strain downward as in defecation. Inspect for Pilonidal sinus or cyst at the sacro- coccygeal area, and give description.

*Palpation: (PR examination) Spread the buttocks apart with your non dominant hand. Gloved index gently placed against the anal verge, and with firm pressure in direction of umbilicus as the rectal sphincter relaxes. Ask client to lighten the sphincter around your finger to examine muscle strength. Mucosa of the anal canal is palpated for tumor or polyps. * Assess normal cervix in female which felt as small round mass during P.R examination.

*Variations from health which can be detected during rectal examination: Pilonidal cyst or sinus. Pruritus anus. Rectal tenesmus. Fecal impaction Anal fissure. Fistula in anus. Hemorrhoids: External painful & internal painless unless complicated. Rectal polyps. Rectal prolapse: e.g. in case of internal hemorrhoids. Anal incontinence. Abscesses or masses e.g. Ischio-rectal abscess, peri-rectal obstruction.