Abdominal Assessment

Objectives of Abdominal Assessment

• Define terminology related to abdominal assessment.
• Recall abdomen's anatomy and physiology.
• Identify necessary equipment and supplies for abdominal assessment preparation.
• Identify proper positioning before and during abdominal assessment.
• Describe technique variations required for abdominal assessment.
• Explain performing abdominal assessment.
• Recognize normal and abnormal assessment data.
• Differentiate between normal and abnormal assessment data.

Terminology

• Abdomen refers to a large oval cavity, extending from the diaphragm to the brim of the pelvis
• Aneurysm is a defect or sac formed by dilation in an artery wall
• Anorexia is the loss of appetite
• Ascites is the abnormal accumulation of serous fluid within the peritoneal cavity
• Borborygmi refers to rumbling sounds from gas moving through the intestines, commonly called stomach "growling.”
• Bruit is a blowing, swooshing sound heard through a stethoscope when an artery is partially occlude
• Cholecystitis is the inflammation of the gallbladder
• Costal Margin is the lower border of the rib margin formed by the edges of the 8th, 9th, and 10th ribs
• Hepatomegaly is the abnormal enlargement of the liver
• Hernia is the abnormal protrusion of bowel through weakening in abdominal musculature
• Linea alba is the midline tendinous seam joining the abdominal muscles
• Paralytic ileus is a complete absence of peristaltic movement
• Peritoneal friction rub is the rough grating sound heard through a stethoscope over peritoneal inflammation sites
• Peritonitis is the inflammation of the peritoneum
• Pyrosis, also know as heartburn, is a burning sensation in the upper abdomen from reflux of gastric acid
• Rectus abdominis muscle refers to midline abdominal muscles extending from the rib cage to the pubic bone
• Scaphoid abdomen describes an abnormally sunken abdominal wall
• Splenomegaly describes abnormal enlargement of the spleen
• Striae (linia ablicantes) presents as a silvery white or pink scar
• Suprapubic is the name of the abdominal region just superior to the pubic bone
• Tympany a high-pitched, musical, drumlike percussion note heard when percussing over the stomach and intestine
• Umbilicus is the depression on the abdomen marking the entry site of the umbilical cord
• Viscera are the internal organs
• Solid viscera is a collective term for solid internal organs in the upper abdomen, including the liver, pancreas, spleen, adrenals, and kidneys, as well as the ovaries and uterus.

Health Assessment Questions

• Do you have any chronic diseases? If yes, describe them.
• Do you take any medications? If so, what and how often, and are you taking them as prescribed?
• How often do you have a bowel movement? When was your last bowel movement? Describe the color and consistency of the stool.
• Have you experienced problems with your abdomen or digestive system in the past, such as with the esophagus, stomach, intestines, liver, gallbladder, pancreas, or spleen? If yes, describe.
• Have you had surgery on your abdomen or urinary tract? If yes, describe.
• Have you had urinary tract problems in the past? If yes, describe.
• Is there a family history of GI system diseases like GERD, peptic ulcer disease, stomach cancer, or colon cancer?
• Is there a family history of urinary tract diseases like kidney stones, kidney cancer, or bladder cancer?
• Do you drink alcohol? If so, how much and how often? When was your last drink?
• Do you smoke? If so, how much and for how long? Have you considered stopping or cutting down?

Assessment Technique Sequence

• Inspection
• Auscultation
• Percussion
• Palpation

Types of Percussion Sounds

• Resonance is a low-pitched, hollow sound with moderate duration.
• Hyperresonance is also low-pitched but more booming, with a longer duration than resonance.
• Tympany is high-pitched and drum-like, having a longer duration than resonance and hyperresonance.
• Dullness is a quiet thud with a high pitch and short duration.
• Flatness is quieter than dullness, with an even shorter duration and a high pitch.

Preparation for Abdominal Assessment

• Introduce yourself to the patient.
• Verify the patient's name/identity.
• State the purpose or explain the procedure.
• Prepare necessary equipment/materials: stethoscope, small ruler/tape measure, marking pen, small pillow.
• Wash hands.
• Instruct the patient to void prior to the procedure.
• Expose the area from the epigastric area to the symphysis pubis while ensuring privacy.
• State the sequence of steps in assessing the abdomen (IAPP) and their rationale

Inspection

• Identify the four abdominal quadrants and the organs located within each quadrant.
• Inspect the skin, noting color, venous patterns, and integrity.
• Inspect the umbilicus for position and color.
• Inspect the abdomen for contour, symmetry, and surface motion.
• State the normal and possible abnormal findings in each step

Auscultation

• Auscultate for bowel sounds, using the diaphragm of the stethoscope in the sequence of RLQ – RUQ – LUQ – LLQ, listening to each quadrant for up to 1 minute, to a maximum total of 5 minutes
• Identify the types of bowel sounds
• Identify different vascular sounds heard on auscultation.
• Bruits are low-pitched, murmur-like sounds over the abdominal aorta, renal, iliac, and femoral arteries.
• Venous hums are not normally heard in the epigastric and umbilical areas.
• Peritoneal friction rubs not normally over the liver and spleen.
• Locate the different areas where vascular sounds may be auscultated.

Percussion

• Percuss all four quadrants, noting areas of tympany and dullness, moving in an up-and-down manner starting from the RLQ.
• Percuss and measure the liver span at the midclavicular and midsternal lines to assess the size of the organ.
• Percuss for the spleen at the left mid-axillary line between the 6th and 10th ribs.
• Percuss for dullness downward in the Left MAL, beginning with lung resonance, until splenic dullness is heard.
• Have the client inhale deeply and hold their breath during percussion.
• Percuss the kidney using the "kidney punch" technique. Place the flat part of the left palm on the area of the 12th rib, right side, and punch the back of the left hand with the right. Repeat on the left side, placing the palm slightly higher. Normally, there should be no tenderness, and tenderness may indicate a kidney problem.

Palpation

• Identify area and proper hand placement/position for liver palpation.
• Identify area and proper hand placement/position for spleen palpation.

Special Maneuvers

• Perform maneuvers to assess the presence of ascites, including measuring the abdominal girth using the same rule:
• Perform the Fluid Wave Test with the patient in a supine position with pressure applied to the mid-abdomen by either the patient or examiner and the examiner having one hand on either flank; a positive test (+) will show a detectable shock wave of fluid with fingertips on one flank when a sharp tap to the opposite flank occurs.
• Perform Shifting Dullness by having the patent in a supine position and percuss across the abdomen with the point of transition from tympany to dullness. Next, have the patient roll on his/her side away from the examiner and percuss from the umbilicus to the flank area. The test is positive when the area of tympany shifts towards the side of the patient.
• Perform maneuvers to assess the presence of appendicitis:
  • Rebound tenderness, or Blumberg’s Sign, notes pain upon removal of pressure in the abdomen. Tests for appendicitis.
  • Psoas Sign, extending the leg causes discomfort
  • Obturator Sign records pian with rotation of the right leg internally at the hip. With the positive sign, the obturator muscle will contacts with appendix
  • Rovsing’s sign, palpation of the left lower quadrant of a person's abdomen increases the pain felt in the right lower quadrant
• Perform maneuvers to test for cholecystitis. In Murphy's sign, the patient asks to inhale while the examiner's fingers are hooked under the liver border at the bottom of the rib cage; inspiration will cause the gallbladder to descend onto the fingers, producing pain if the gallbladder is inflamed.
• Perform Tests For asterixis, which shows persistent involuntary flapping tremor (classic sign of hepatic coma)