1. Health Assessment Abdominal Assessment
NUR 248

2. Anatomy Review
Abdomen: large oval cavity from diaphragm down to brim of pelvis
Linea alba: central tendinous seam
Rectus abdominus: set of abdominal muscles forms strip extending the length of midline- often palpable (six pack)
Internal/External obliques: lateral muscles of the abdomen

4. Abdomen Viscera: internal organs.
Solid viscera: firm organs- liver, pancreas, spleen, adrenal glands, kidneys, ovaries, and uterus.
Liver (RUQ) and right kidney may be palpable.
Spleen: soft mass lymphatic tissue of LUQ- normally not palpable.
Hollow viscera: usually non-palpable unless contents are present ( stool in colon) – stomach, gallbladder, small intestine, colon, and bladder.

6. Abdomen Aorta: left to midline upper part of abdomen.
Renal arteries branch off of the abdominal aorta about 4cm below epigastric area, above the common iliac arteries.
Aorta also bifurcates 2cm below umbilicus into the right and left common iliac arteries which become the femoral arteries in the groin area (easily palpated).

8. History Dysphagia Food Intolerance Abdominal Pain (PQRST)
Nausea/Vomiting
Bowel Habits
Hx of GI problems, surgeries
Medications
Diet/Nutrition – exercise pattern

9. Developmental Considerations for History
Infants
Tolerance to newly introduced foods
Adolescents
Anorexia/bullemia
Elderly
Ability to acquire/prepare foods
Social isolation

10. Overview
Inspect- skin color, lesions, scars, movements, position of umbilicus
Auscultate- bowel sounds, bruits, venous hum
Percuss- tympany, shifting dullness, liver span, spleen size
Palpate-
superficial (masses, tenderness) ½ to 1 cm
Deep masses (tenderness) 2-3 cm
Organ size (liver, kidney, spleen)
Rebound tenderness
Fluid wave

11. Abdomen: Landmarks Abdomen: usually divided into four quadrants
RUQ, LUQ, RLQ, LLQ
Epigastric: area between the costal margins
Umbilical: area around umbilicus
Hypogastric/suprapubic: area above pubic bone
Costovertebral angle: where the tip of the 12th rib forms an angle with the vertebral column (kidneys lie in this area, right lower due to liver).

13. Which organs lie in each quadrant?
RUQ
RLQ
LUQ
LLQ

14. Developmental Considerations
Infants/Children
Newborn: umbilicus prominent- two arteries and 1 vein
Childrens organs easier to palpate d/t poor abdominal wall musculature
Pregnancy:
N/V early sign
Heartburn
Constipation d/t decreased gastric motility
Uterus is displaces intestines upward and posteriorly with appendix more superior and lateral than normal – be careful with appendicitis in these patients

15. Developmental Considerations
Aging Adult:
Salivation decreases
Esaphogeal emptying delayed: risk of aspiration with supine feeding position
Gastric acid secretion decreases – interferes with vitamin B12 absorption (pernicious anemia)
Liver size/function decreases: careful with meds metabolized by liver (increased side effects)
Constipation; often misinformed about normal bowel movement timing (peristalsis decreases)

16. Abdominal Assessment
Inspection
Symmetry side to side along with pulsation or movement (peristalsis)
Contour (flat, round, convex, distended, scaphoid, protuberant)
Skin condition (scars, striae, venous pattern)
Umbilicus (midline, inverted, everted)

18. Auscultation. Bowel sounds
listen in all 4 quadrants, begin with RLQ [where ilieocecal valve is located, most likely to hear bowel sounds here]
proceed clockwise using diaphragm of stethoscope. (Some texts say to use bell).
BS occur every 5-15 seconds =normal bowel or active bowel sounds
Absence of bowel sounds can be established after auscultating for 5 minutes in one area.
Bowel sounds are tinkling, gurgling sounds caused by fluid & air moving through the small intestine.
BS documented as:
Hypoactive.
Active.
Hyperactive (borborygmi).

19. Vascular Sounds (listening for bruit or rushing sound of blood rushing through stenosed vessel or aneurysm)
Abdominal Aorta (epigastric area, just left of midline
Renal Arteries (~2in below aorta to the R &L of midline
Illiac Arteries (~4 in below renal arteries to R & L of umbilicus
Femoral – (~2-3 inches below illiac arteries R and L, in line with illium

21. Percussion
General
Organs (liver, spleen, Kidney tenderness [fist percussion])
Predominant percussion note is tympany because of air in intestines and hollow stomach with dullness over fluid or fecal matter and over solid organs.

23. Percussion of liver border
Can percuss the borders of solid organs: liver and spleen.
Liver; begin RMCL at level of umbilicus and percuss toward head until dullness is heard. This equals lower liver border. Percuss from nipple RMCL down to dullness. This equals the upper border of the liver. Normal liver span is ~6-12cm

24. Percussion of Spleen
Percuss anterior to mid-axillary line beginning at level of umbilicus up, and beginning at level of nipple down until dullness is noted.

27. Palpation
Light (muscle tone, tenderness, superficial masses) less than 1 cm deep
Deep (masses, tenderness) 2-3 cm deep
Organs (Liver, kidneys, spleen)
Rebound Tenderness (may indicate peritoneal inflammation/irritation)
Aorta

28. Abnormal PALPATION Findings
Mass (fecal, fetus, tumor)
If unexpected mass palpated, note;
Location
Size
Shape
Consistency (soft, firm, hard)
Surface (smooth, nodular, irregular)
Mobility (including movement with respiration)
Pulsatility
Tenderness

29. Pain Possible causes: Appendicitis Peritonitis
Cholecystitis (biliary stones)
Pancreatitis
Salpingitis, rupture ovarian cyst
Pelvic Inflammatory Disease
Diverticulitis
Gastric or Duodenal ulcer
Intestinal obstruction
Vovulus
Leaking abdominal aneurysm
Renal Calculi
Ectopic pregnancy
Splenic rupture

30. Pain Characteristics Superficial – muscular
Deep – visceral- “achy”, sharp, dull, spasmodic, throbbing, may radiate or refer
May be associated with nausea/vomiting
May be exacerbated by movement or breathing

31. Abnormal findings
Pain (Referred pain)

32. Abdominal Distension Note if firm or soft May be due to Obesity
Air/gas
Ascites (abnormal accumulation of fluid)
Cyst/Mass/Tumor (LLQ, may indicate feces)
Pregnancy

33. Hernia
Protrusion of abdominal contents through the abdominal wall muscles but beneath the skin.
Umbilical
Inguinal
Diastasis Recti
Incisional
Have pt lift head or bear down to accentuate

34. Abdominal Trauma Ruptured spleen/liver (blood rich organs)
Difficult to ascertain bleeding into the abdomen because it can hold most of the body’s blood volume.
Distension (hard/firm) (BP, restlessness, confusion)
Bruising (dependent, umbilical)
If splenic or liver rupture suspected (by history report), shouldn’t palpate.
This is a surgical emergency.

35. Special Assessment Techniques
Rebound Tenderness (Blumberg’s Sign)
Indicates peritoneal inflammation/irritation)
Hand perpendicular to abd, push down slowly and remove quickly (appendicitis)
Inspiratory Arrest (Murphy’s Sign)
Indicates cholecystitis
Hold fingers under liver border and have pt inhale, positive if painful and inspiration is halted due to pain

37. Special Assessment Techniques
Iliopsoas Muscle Test
Indicated if acute appendicitis suspected.
Have pt flex leg at hip, press down on thigh, if pain felt in LLQ=positive test
Obturator Test
Indicated for suspected appendicitis
Flex leg, internally and externally rotate hip. If causes pain=positive test.

39. Special Assessments Ascites Positive fluid wave
Shifting dullness to percussion (dependent)
Ascites can compromise ventilation with increased abdominal pressure