Nursing Abdominal Assessment Quiz

Abdominal Assessment

• The examination includes: health history, inspection, auscultation, percussion, and palpation
• It includes the abdominal and pelvic areas
• Nurses should create an atmosphere of compassion, openness, and mutual trust

Nursing History

• Important information includes: nausea, vomiting, dysphagia, indigestion, heartburn, changes in bowel movements (frequency, consistency, color, etc.), use of laxatives, rectal bleeding, pain, tarry stools, bloating, distention, gas
• Appetite changes, recent changes in diet patterns, unplanned weight changes, urinary symptoms (burning, urgency, incontinence, hematuria), vaginal/penile discharge, perineal changes, menstrual history, and last menstrual period are also important.
• Past medical history, surgical history, family medical history, and medications (prescription, OTC, herbals) should be documented.
• History of alcohol use is important to help clinicians understand potential causes for liver problems.

Supplies

• Stethoscope, adjustable light source, small pillows, tape measure, and marking pencil
• Ask the patient to void prior to the exam
• Have the patient point to areas of discomfort and assess those last
• Ensure the patient is warm with adequate clothing or blankets to preserve privacy
• The room must be quiet enough to hear bowel sounds
• Assist the patient to a supine position with arms at their sides, use pillows to support the head and keep knees slightly bent to reduce abdominal muscle tension

Order of Assessment

• Perform inspection first, followed by auscultation, percussion, and palpation
• Stand at the patient’s side and look across the abdomen and at the foot, then look towards the head.
• Check for symmetry, masses, irregularities, visible aortic pulsations, and peristalsis.

Contour/Shape

• Should be symmetrical. Common shapes include:
  • Flat: normal
  • Rounded: obese
  • Scaphoid: emaciated or cachectic
  • Protuberant: larger than rounded, moderate obesity
  • Distended: tight, shiny skin, may indicate ascites

Skin

• Should have even coloration.
• Check for areas of ecchymosis (bruising).
• Dilated superficial veins may be a sign of liver disease.

Ascites

• Ascites is fluid build-up in the abdomen
• May be associated with liver or heart problems.

Lesions and Rashes

• Note location, size, and shape.
• Striae (stretch marks) are silver-white marks and can be caused by pregnancy or weight loss.
• Check for scars and ensure they match the medical history.

Umbilicus

• A protruding or inverted umbilicus is normal.
• Note any bruising around the umbilicus.

Hernia

• A hernia is a protrusion of abdominal organs/bowel through the muscle wall
• Hernias may cause an upward protrusion of the umbilicus.

Tubes and Drains

• Document what is infusing or draining. This may include:
  • Nasogastric tube (NG tube)
  • Feeding tube

Stoma

• A stoma is a surface opening on the abdominal wall
• Ostomy is a surgically created opening between the abdominal wall and the intestine, bowel, or bladder.
• Note the type of appliance used and any drainage.

Abdominal Girth

• Measure around the abdomen at the level of the umbilicus.
• Use a tape measure and mark the abdomen on both sides to ensure repeated measurements are at the same site.

Auscultation

• Done first after inspection because percussion and palpation may alter bowel sounds.

Bowel Sounds

• Sounds caused by air mixing with fluid during peristalsis.
• Use the diaphragm of the stethoscope and listen in a regular pattern: RLQ, RUQ, LUQ, LLQ.
• Normal bowel sounds are irregular, high-pitched, gurgling sounds heard 5-30 times per minute.

Description of Bowel Sounds

• Normal: Audible
• Hyperactive (borborygmi): High-pitched, loud, rushing sounds heard frequently (every 3 seconds). May indicate increased intestinal motility. Associated with cramping, diarrhea, early bowel obstruction, or use of laxatives.
• Hypoactive: Extremely soft and infrequent sounds, approximately 1-2 per minute.
• Absent: Bowel sounds cannot be auscultated. Auscultate in all four quadrants for 3-5 minutes before concluding that bowel sounds are absent. Indicates cessation of intestinal motility. If possible, listen again after the patient has moved around and ask another nurse to listen.

Percussion

• Performed by an advanced practitioner
• Used to detect the size and location of abdominal organs or to detect air and fluid in the abdomen, stomach, or bowel.