1. Abdominal Examination By Arinitwe Elizabeth

3. Peritoneum Peritoneum: the abdominopelvic cavity is lined with a thin shiny serous membrane that also folds back to cover most of the organs within the cavity Mesentary: subdivsion of the peritoneum- it is a double layer of the peritoneum that encloses a portion of the abdominal viscera, namely the intestines, and attaches it to the abdominal wall. Contains blood vessels, nerves, lymphatic vessels and hold the organs in place and stores fat.

8. 9 Region System- British right and left hypochondrium,hypochondrium right and left flank, right and left iliac fossa,iliac fossa the umbilical area,umbilical area the epigastrium and the suprapubic region

9. Structure RUQ – Liver – Gallbladder – Duodenum – Head of pancreas – Right kidney and adrenal gland – Hepatic flexure of colon – Part of ascending and transverse colon LUQ – Stomach (EPIGASTRIC) – Spleen – Left lobe of liver (EPIGASTRIC) – Body of pancreas (EPIGASTRIC) – Left kidney and adrenal gland – Splenic flexure of colon – Part of transverse and descending colon Slide 21-9

10. Structure Right lower quadrant (RLQ) – Cecum – Appendix – Right ovary and tube – Right ureter – Right spermatic cord Left lower quadrant (LLQ) – Part of descending colon – Sigmoid colon – Left ovary and tube – Left ureter – Left spermatic cord Slide 21-10

11. Structure  Midline  Aorta  Uterus, if enlarged  Bladder, if distended Slide 21-11

12. Subjective Data Abdominal Pain Anorexia Nausea or Vomiting Bowel Movements – Constipation or diarrhea – Melena or hematochezia

13. Abdominal Pain Onset: when did it begin? Location: where is the pain? Duration: How long have you had it? Character: Constant or come and go? Occur before or after meals? Sharp, pressure, cramping, burning, aching, dull? Associated with: fever, chills? Nausea/vomiting? Diarrhea/constipation? Anorexia? Blood in stool or vomit? Menses? Change in urination? Aggravating/Relieving: food make it better or worse? Heating pad? Position changes?

14. Anorexia – Loss of appetite from gastrointestinal disease, as a side effect to some medications, with pregnancy, or with systemic or psychological disease – Good indicator on how sick someone is and how severe the abdominal discomfort is – Usually accompanies another GI/medical process – History is crucial to narrow down your differentials

15. Nausea and Vomiting Common with GI diseases (peptic ulcer disease, gastroenteritis, peritonitis, hepatitis, appendicitis, etc), many medications, early pregnancy – Onset/Character: when did it begin? How often? What is the color? What did you eat in the last 24 hours? Any family members with same symptoms? – Associated with: pain, diarrhea, fever, chills? Hematemesis (either red blood or coffee-ground emesis) suggests upper GI bleeding (stomach/duodenum)

16. Bowel Movements Assess usual bowel habits then assess how they have changed – How often do you have a bowel movement? – When was your last BM? – What is the color? Consistency? – Any diarrhea (increased frequency) or constipation (decreased frequency)? – Are you passing gas/flatus? Melena: black tarry stool suggestive of upper GI bleeding (usually stomach/duodenum) due to digestion of blood as it makes it way through the GI tract. Hematochezia (red or maroon blood/stool) is usually due to lower GI bleeding (below the duodenum)

17. Objective Data Preparation – Bladder emptied – Warm room and hands and stethoscope – Patient in supine position with knees bent, arms at side (relaxes abdominal musculature) – Inquire about painful areas– examine these areas last – Use distraction to relax patient (deep breathing, low, soothing voice, engage patient in conversation)

18. Objective Data  Inspection, Auscultation, Percussion, Palpation Inspect the abdomen – Stand on right side and look down the abdomen – Determine the CONTOUR of the abdomen from the rib margin to the pubic bone The contour is a reflection of nutritional state or possible reflects disease processes Flat, Scaphoid, Rounded, Protuberant

19. Contour Slide 21-19

20. Objective Data- Inspection Note the symmetry of the abdomen – Is there any localized bulging, visible mass, asymmetric shapes? Localized bulging with hernias (protrusion of abdominal viscera through abdominal opening in muscle wall) Asymmetry or visible mass with enlarged liver or spleen or tumors Bulging at flanks with ascites (accumulation of fluid in peritoneal cavity) – Note changes with deep breaths and sitting up

21. Objective Data- Inspection Inspect the umbilicus: normally it is midline, inverted with no signs of inflammation or hernia Inspect the skin of the abdomen: normally it is smooth and even with homogenous color – Erythema with inflammation/infection – Jaundice with liver disease – Skin taut/tight with ascites – Striae after pregnancy or rapid weight gain – Scars from previous surgeries

22. Objective Data- Inspection Inspect for pulsations or movements – Normally, can see slight pulsations from aorta beneath the skin in the epigastric area (abnormal if bounding) – Normally, may see respiratory movements in abdomen (especially in children) – In thin persons, may see waves of peristalsis that are slow (abnormal if marked visible peristalsis) Inspect patient’s face throughout examination of abdomen – Restlessness/can’t sit still with coliky pain (gallbladder, bowel obstruction, kidney stones) – Absolute stillness with peritonitis – Grimacing when experiencing pain or tenderness

23. Objective Data- Auscultation Auscultate Bowel Sounds – Begin in RLQ at the ileocecal valve area (normally have bowel sounds present) – Note character and frequency of bowel sounds Normal: high pitched, gurgling, occurring irregularly 5-30 times per minute Abnormal: – Hyperactive sounds: loud, high pitched, rushing, tinkling sounds that signal increase motility= Borborygymi » Early bowel obstruction, gastroenteritis/diarrhea – Hypoactive sounds or absent: abdominal surgery or with inflammation of the peritoneum or from late bowel obstruction signaling decrease motility » Silent abdomen: must listen for 5 minutes

24. Objective Data- Auscultation Auscultate for Vascular Sounds – Note presence of any vascular sounds or BRUITS (pulsatile blowing sound that occurs with stenosis or occlusion of an artery – Use firmer pressure and auscultate: Aorta Renal arteries Iliac Femoral arteries – Usually no bruits are heard

26. Objective Data- Percussion Percussion – General Tympany Percuss lightly in all four quadrants to assess for tympany and dullness; move clockwise Tympany should predominate because air in the intestines rises to surface when patient is supine Dullness: distended bladder (fluid), adipose, fluid, mass Hyperresonance: gaseous distention

27. Objective Data- Percussion Percuss liver span – Measure height of liver in the right midclavicular line – Begin in area of lung resonance and percuss down the interspaces until the sounds changes to dull Mark this spot (usually around 5 th intercostal space) – Then find abdominal tympany and percuss up in the midclavicular line until changes to dull Mark this spot (normally at right costal margin)