GIT Assessment PDF

GIT Assessment Nine regions system: The abdomen is divided into nine regions by four intersecting lines: 1. Two horizontal. 2. Two vertical lines.  Internal anatomy A thin, shiny, serious membrane called the peritoneum lines the abdominal cavity (parietal peritoneum) and also prov...

GIT Assessment Nine regions system: The abdomen is divided into nine regions by four intersecting lines: 1. Two horizontal. 2. Two vertical lines.  Internal anatomy A thin, shiny, serious membrane called the peritoneum lines the abdominal cavity (parietal peritoneum) and also provides a protective covering for most of the internal abdominal organs (visceral peritoneum). Within the abdominal cavity are structures of several di erent body systems (abdominal visceria) and can be divided into two types: 1. Solid viscera are those organs that maintain their shape consistently as liver. 2. The hollow viscera consist of structures that change shape depending on their contents; as stomach.  Liver The liver is the largest solid organ in the body. It is located below the diaphragm in the RUQ of the abdomen and extended to the left mid clavicular line. The liver often extends just below the right costal margin, where it may be palpated.  The gallbladder The gallbladder is a muscular sac approximately 10 cm in length. It is located under the posterior surface of the liver lateral to the mid- clavicular line. It is not normally palpated because it is di cult to distinguish between the gallbladder and the liver.  Pancreas The pancreas, located mostly behind the stomach, deep in the upper abdomen, is normally not palpable. It is long gland, extending across the abdomen from the RUQ to the LUQ.  Spleen The spleen is approximately 7cm in width and is located above the left kidney, just below the diaphragm at the level of the 9th, th th 10 ,11 ribs. It is posterior to the left mid-axillary line and posterior and lateral to the stomach. this soft, flat structure is normally not palpable.  Kidneys The kidneys are located high and deep under the diaphragm. These glandular, bean-shaped organs, measuring approximately 10 x 5x 2.5 cm, are considered posterior organs and approximate with the level of the T12 to L3 vertebrae. The tops of both kidneys are protected by the posterior rib cage. It is best to assess for kidney tenderness at the costovertebral angle.  Uterus The pregnant uterus may be palpated above the level of the symphysis pubis in the midline. The ovaries are located in the RLQ and LLQ and are normally palpated only during a bimanual examination of the internal genitalia.  Stomach The location of the stomach marks the beginning of the abdominal cavity. It is a distensible, flask-like organ located in the LUQ, just below the diaphragm and in between the liver and spleen. The stomach is not palpable.  Small intestine The small intestine is actually the longest portion of the digestive tract (approximately 7.0 m long), but is named for its small diameter (approximately 2.5 cm). The small intestine lies coiled in all four quadrants of the abdomen, but is not normally palpated.  The colon The colon, or large intestine, has a wider diameter than the small intestine (approximately 6.0 cm) and is approximately (1.4 m long). It originates in the RLQ, where it attaches to the small intestine at the ileocecal valve. The colon is composed of three major sections: 1. The ascending colon. 2. The transverse colon. 3. The descending colon. The transverse and descending colon may also be felt on palpation; whereas ascending colon may feel softer.  The urinary bladder The urinary bladder is a distensible muscular sac located behind the pubic bone in the midline of the abdomen. A bladder filled with urine may be palpated in the abdomen above the symphysis pubis.  Vascular structures The abdominal organs are supplied with arterial blood by the abdominal aorta and its major branches. Pulsations of the aorta are frequently visible and palpable midline in the upper abdomen. The aorta branches into the right and left iliac arteries just below the umbilicus. Pulsations of the right and left iliac arteries may be felt in the RLQ and LLQ.  Nursing History Current symptoms: Abdominal pain: occurs when specific digestive organs or structures are a ected by chemical or mechanical factors such as inflammation, infection, distention, stretching, pressure, obstruction, or trauma. - Quality or character of the pain (burning, colicky, pressure). - Onset. - Location (primary or referred). - Timing and relationship of temporal events. - Precipitating factors; exacerbating factors or alleviating factors. - The presence of associated signs and symptoms. :Areas of referred pain :Areas of referred pain  Nursing History Indegestion (dyspepsia): often described as heartburn (pyrosis), may be an indication of acute or chronic gastric disorders, including hyperacidity, gastroesophageal reflux disease, peptic ulcer disease and stomach cancer. - Certain factors as food, drinks, alcohol, medications, stress aggravate indigestion.  Nursing History Nausea: may reflect gastric dysfunction and is also associated with many digestive disorders and disease of the accessory organs, such as the liver and pancreas as well as with renal failure and drug intolerance. - Nausea may also be precipitated by dietary intolerance, psychological triggers or mentruation. - Nausea may also occur at particular times such as early in the day with some pregnant patients “morning sickness”, after meals with gastric disorders or between meals.  Nursing History Vomiting: is associated with impaired gastric motility or reflex mechanisms. Description of vomitus (emesis) is a clue to the source. For example: Bright hematemesis is seen with bleeding esophageal varices and ulcers of the stomach or duodenum.  Nursing History Loss of appetite (anorexia): - It is general complain often associated with digestive disorders, malignancies and psychological disorders. - Significant appetite changes and food intake may adversely a ect the patient’s weight and put the patient at risk. - Older patients often experience a decline in appetite and are at risk for nutritional imbalance.  Nursing History Changes in bowel patterns: Changes in bowel patterns must be compared to usual patterns for the patient. Normal frequency varies from two to three times per day to three times per week..  Nursing History Changes in bowel patterns: Constipation- Diarrhea: Constipation is usually defined as a decrease in the frequency of bowel movements or the passage of hard and possibly painful stools. Diarrhea is defined as frequency of bowel movements producing unformed or liquid stools. Bloody and mucoid stools may be associated with inflammatory bowel diseases. Clay-colored, fatty stools may be associated with mal- absorption syndromes.  Nursing History Other signs and symptoms: 1. Yellow discoloration of skin. 2. Itching of the skin. 3. Dark urine (yellow-brown or tea colored). These symptoms should be evaluated for the possibility of liver disease.  Nursing History Past History: GIT disorders… 1. Ulcers. 2. Gastrointestinal reflux. 3. Inflammatory or obstructive bowel disease. 4. Pancreatitis. 5. Gallbladder. 6. Diverticulosis. 7. Appendicitis. Diverticulosis, is the condition of having diverticula in the colon, which are outpocketings of the colonic mucosa and submucosa through weaknesses of muscle layers in the colon wall. These are more common in the sigmoid colon, which is a common place for increased pressure.  Nursing History Past History: 1. Urinary tract disorders: Such as: Infections; Kidney disease; Kidney stones. 2. Liver disorders: Viral hepatitis (type A, B, or non-A, non-B) any type of viral hepatitis may cause liver damage. 3. Abdominal surgery or trauma. 4. Prescription or OTC medications: Medications may produce side e ects that adversely a ect the GIT  Nursing History Family history: Family history of certain disorders increases the patient’s risk for those disorders (colon, stomach, pancreatic, liver, kidney, or bladder cancer, liver disease, gallbladder disease, kidney disease). Genetic testing can now identify the risk for certain cancers (colon, pancreatic and prostate) and other diseases. Patient awareness of family history can serve as a motivation for health screening and positive health promotion behaviors.  Nursing History Life-style and health practices: 1. Alcohol ingestion can a ect the GIT organs such as stomach, pancreas and liver. 2. A baseline dietary and fluid survey helps determine nutritional and fluid adequacy and risk factors for altered nutrition, as well as other disorders such as constipation or diarrhea or diseases such as cancer. 3. Regular exercise.  Collecting Objective Data The sequence for assessment of the abdomen di ers from the typical order of assessment. Auscultate after inspection so as not to alter the patient’s pattern of bowel sounds. Percussion and then palpation follow.Auscultation.Inspection auscultation..Percussion.Palpation  Techniques for Exam 1. Ask the patient to empty the bladder. 2. Drape the patient from the lower rib cage to the pubic area. 3. Adjust the bed level and approach the patient from the right side. 4. A flat pillow may be placed under the patient’s head for comfort. 5. Place a small pillow under the patient’s knees to help relax the abdominal muscles. 6. Ask the patient to keep the arms at the sides or folded across the chest. Raising arms above the head or folding them behind the head will tense the abdominal muscles.  Techniques for Exam 7. Keep the room warm. Chilling can cause abdominal muscles to become tense. 8. Warm the hands and stethoscope. 9. Speak softly and encourage the patient to perform breathing exercises during uncomfortable procedures to relax “Distraction techniques”. 10. Before the abdomen is touched, ask the patient about painful or tender areas. 11. Assess painful areas last to help prevent the patient from becoming tense.  Equipment 1. Small pillow or rolled blanket. 2. Centimeter ruler. 3. Stethoscope. 4. Marking pen. 5. Flexible tape measure 6. Gloves. There should be adequate exposure of the abdomen for proper inspection. The patient should be exposed from the inferior chest to the anterior iliac spines bilaterally.  Inspection Inspect the skin: Color: 1. Normally, skin on abdomen may be paler than general skin tone. 2. Purple discoloration at the flank (Grey Turner sign) indicates bleeding within the abdominal wall. 3. The yellow blue of jaundice may be more apparent on the abdomen. 4. Pale, taut skin is seen with ascites. 5. Redness area may indicate inflammation. 6. Bruises or areas of local discoloration are abnormal. Grey Turner's sign refers to bruising of the flanks. The bruising appears as a blue discoloration, and is a sign of retroperitoneal hemorrhage, or bleeding behind the peritoneum.. Cullen's sign is superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. It may be accompanied by Grey Turner's sign , which may then be indicative of pancreatic necrosis with retroperitoneal or intraabdominal bleeding.  Inspection Inspect the skin: Vascularity: 1. Scattered fine veins may be visible. 2. Dilated superficial capillaries without a pattern may be seen in older patients. They are more visible in sunlight. 3. Dilated veins may be seen with cirrhosis of the liver, inferior vena cava obstruction, portal hypertension or ascites. 4. Dilated surface arterioles and capillaries with a central star (spider angioma) may be seen with liver disease or portal hypertension..Caput Medusae  Spider angioma  Inspection Inspect the skin: Striae: 1. Old silver-white striae or stretch marks from past pregnancies or weight gain are normal. 2. Dark bluish-pink striae are associated with Cushing syndrome. 3. Striae may be caused by ascites that stretch the skin from liver failure or liver disease. Old silver-white striae Dark bluish-pink striae  Inspection Inspect the skin: Scars- Lesions / rashes: - Ask the patient the source of any scar and use a centimeter rulers to measure length. - Abdomen is free of lesions or rashes. - Flat or raised brown moles may be seen on the abdomen. - Change in size, color, symmetry of borders and bleeding of moles. - Presence of petechiae. -  Inspection Inspect the umbilicus: 1. Color: - Abdominal skin tone or pinkish. - Bluish-purple discoloration around the umbilicus (Cullen’s sign) indicates intra- abdominal bleeding. 2. Location: - Midline between 3rd – 4 th lumbar vertebrae. - A deviated umbilicus may be caused by pressure from a mass, enlarged organs, hernia, fluid or scar tissue.  Inspection Inspect the umbilicus: 3. Contour: - Recessed (inverted) or protruding no more than 0.5 cm; round or conical. - An everted umbilicus is seen with abdominal distention. - An enlarged, everted umbilicus suggested umbilical hernia.  Inspection Inspect the abdominal contour: 1. Look across the abdomen at eye level from the patient’s right side, from behind the patient’s head, and from the foot of the bed. 2. Measure abdominal girth at the umbilicus if distension is present. 3. Abdomen is flat, rounded, or scaphoid (usually seen in thin adults). 4. Abdomen should be evenly rounded.  Inspection Inspect the contour: 1. A generalized distended abdomen. The major causes of abdominal distention are sometimes referred to as the “6 Fs”: fat, feces, fetus, fibroids, flatulence and fluid. 2. Distention below the umbilicus may be due to a full bladder, uterine enlargement or an ovarian tumor or cyst. 3. Distention of the upper abdomen may be seen with masses of the pancreas or gastric dilation. 4. A scaphoid (sunken) abdomen may be seen with severe weight loss or cachexia related to starvation or terminal illness. A scaphoid (sunken) abdomen both the patients with massive ascites and obesity have abdominal distention, how do we distinguish from each other, you can observe the appearance of the umbilicus, umbilicus is usually deeply inverted in obesity and everted in long—standing ascites  Measuring abdominal girth 1. Measure at the same time of day, ideally in the morning just after voiding. 2. Ideal position is standing; otherwise, use the supine position, with head slightly elevated for orthopneic patients. 3. Use the same position, Measure in same location for all future measurements. 4. It may help to place ballpoint pen ink marks on abdomen to mark the location. 5. Use a disposable or easily cleaned tape measure. 6. Place the tape measure behind the patients and measure at the umbilicus.  Inspection Inspect the symmetry: - Patient’s lies in a relaxed supine position. - Abdomen is symmetric. - No bulging with raised head. - Asymmetry may be seen with organ enlargement, large masses, hernia, diastasis recti or bowel obstruction. Hernia : protrusion of the bowel through the abdominal wall; is seen as a bulging in the abdominal wall (sneezing, cough or lifting heavy object)  Inspection Inspect abdominal movement: a. Respiratory movement. Abdominal respiratory movement may be seen, especially in male patients. But in women the manner of breathing is thoracic respiration  Inspection Inspect abdominal movement: b. Aortic pulsations: A slight pulsation of the abdominal aorta is visible in the epigastrium, extending full length in the thin individuals. Vigorous, wide, exaggerated pulsations may be seen within abdominal aortic aneurysm.  Inspection Inspect abdominal movement: c. Peristaltic waves: Peristaltic waves are normally not seen; may be visible in very thin individuals as slight ripples or waving on the abdominal wall. Peristaltic waves are increased and progress in a ripple-like fashion from the LUQ to the RLQ with intestinal obstruction (especially small intestine).  Inspection Skin (color, vascularity, striae, scars,.lesions or rashes).Umbilicus (color, location, contour).Abdominal contour.Symmetry Abdominal movement (respiratory movement,.aortic pulsations, peristaltic waves)  Auscultation Auscultate for bowel sounds: - Series of intermittent soft clicks and gurgles are heard at a rate of 5 to 30 clicks per minute. - Hyperactive bowel sounds that may be heard normally are the loud, prolonged gurgles characteristic of stomach growling - rumbling noises. - Postoperatively; sounds will return gradually depending on the type of surgery.  Auscultation Auscultate for bowel sounds: - Hypoactive bowel sounds indicate diminished bowel motility; in abdominal surgery or late bowel obstruction - 3 to 5 per minute. - Hyperactive bowel sounds indicate increased bowel motility; - Greater than 34 sounds per minute. Caused by anxiety, infectious diarrhea, irritation of intestinal mucosa from blood, or gastroenteritis. - Decreased or absent bowel sounds signify absence of bowel motility and constitute an emergency that requires immediate referral; may associated with peritonitis or paralytic ileus. Normal bowel sounds occur approximately every 5 to 15 seconds; the number is as high as 15-20 per minute, or roughly, one bowel sound for each breath sound. Bowel sounds may be more active over the ileoceal valve in the RLQ. Uninterrupted bowel sounds may be heard over the ileocecal valve 4 to 7 hours following a meal. Stimulation of peristalsis may be achieved by flicking the abdominal wall with a finger or by dropping ether on the skin.  Auscultation Always auscultate bowel sounds before touching the abdomen – this prevents alteration of bowel sounds. - Use diaphragm of the stethoscope and make sure that is warm before placing it on the patient’s abdomen. - Apply light pressure or simply rest the stethoscope on a tender abdomen. - Begin in the RLQ and proceed clockwise, covering all four quadrants. - Confirm the presence of bowel sounds in each quadrant. - The examiner must listen for at least / up to 5 minutes (minimum of 1 minute per quadrant)  Auscultation Auscultate for vascular sounds : - Use the bell of the stethoscope and listen for bruits over the abdominal aorta and renal, iliac and femoral arties. - Bruits “swoosh” are not normally heard over abdominal aorta or renal, iliac or femoral arteries. - A bruit occurs when blood flow in an artery is turbulent or obstructed. This usually indicates aneurysm or arterial stenosis.  Percussion Percussion: the left and right abdomen should be percussed above and below the umbilicus. Most examiners will percuss 8 or more areas.  Percussion Percuss for tone: - Lightly percuss all four quadrants using a systemic approach. - Generalized tympany predominates over abdomen because of presence of air in the stomach and intestine. - Normal dullness is heard over the liver and spleen. - Dullness may also be elicited over a non- evacuated descending colon.  Percussion Percuss for tone: - Tympany or hyperresonance is heard over a gaseous distended abdomen. - An enlarged area of dullness is heard over an enlarged liver or spleen. - Abnormal dullness is heard over a distended bladder, large masses, or ascites.  Percussion Percuss the liver: - Percuss the span or height of the liver by determining its lower and upper borders. - To assess the lower border, begin in the RLQ at the mid-clavicular line (MCL) and percuss upward. - Note the change from tympany to dullness. - Mark this point; the lower border of the liver dullness is located at the costal margin to 1 to 2 cm below. - Ask the patient to take deep breath; The lower border of the liver dullness may descend to 1 to 4cm below the costal margin on deep inspiration.  Percussion Percuss the liver: - To assess the upper border, percuss over the upper right chest at the MCL and percuss downward, noting the change from lung resonance to liver dullness. - Mark this point; it is the upper border of liver dullness. - The upper border of liver dullness is located between the left 5th to 7 th intercostal spaces.  Percussion Percuss the liver: - Measure the distance between the two marks; this is the span of the liver. - The normal liver span at the MCL is 6 to 12 cm (greater in men and taller patients, less in shorter patients).  Percussion: Liver span The liver span is estimated by percussion. Remember that it is easier to hear the change from resonance to dullness – so proceed with percussion from areas of resonance to areas of dullness. Upper border: In the midclavicular line start percussing in the chest moving down towards the abdomen about ½ to 1 cm at a time. Note where the percussion notes change from resonate to dull. Lower border: In the midclavicular line begin percussion below the umbilicus and proceed upward until dullness is encounter. Liver span is normally 6 to 12 cm in the The distance between the two areas where midclavicular line. dullness is first encountered is the liver  Percussion Percuss the liver: - Repeat percussion of the liver at the mid- sternal line (MSL). - The normal liver span at the MSL is 4 to 8 cm. - Hepatomegaly is defined by a liver span that exceeds normal limits (enlarged) and is seen with liver tumors, cirrhosis, abscess and vascular engorgement.  Percussion Percuss the liver: - Atrophy of the liver is indicated by a decreased span. - A liver in a higher position. - A liver in a lower position. - A liver in a lower or higher position should have a normal span. A liver in a higher position than normal may be caused by conditions such as abdominal mass, ascites or paralyzed diaphragm. A liver in a lower position than normal may be caused by emphysema.  Percussion Percuss the spleen: - Begin posterior to the left mid-axillary line (MAL) and percuss downward, noting the change from lung resonance to splenic dullness - the spleen is an oval area of dullness approximately 7 cm wide located near the left 10th rib, slightly posterior to the MAL. - Splenomegaly is defined by an area of dullness greater than 7 cm wide. Dull tone over spleen (9 th – 11 th ribs)  Percussion Perform blunt percussion on the liver : - Blunt (indirect fist) percussion is performed to assess for tenderness in di cult- to- palpate structures. - Perform blunt percussion on the liver by placing the left hand flat against the lower right rib cage. - Use the ulnar side of the right fist to strike the left hand. - Normally no tenderness is elicited. - Tenderness elicited over the liver may be noted with inflammation or infection (hepatitis or cholecystitis).  Percussion Perform blunt percussion on the kidneys: - Perform blunt percussion on the kidneys at the costovertebral angles (CVA) over the th 12 rib. - This technique requires the patient is sitting with the back to the examiner. - Normally no tenderness or pain is felt; only a dull thud. - Tenderness or sharp pain elicited over the CVA suggests kidney infection (pyelonephritis), calculi or hydronephrosis. Abdominal Palpation Palpate lightly in all 4 quadrants. Press down around 1 cm. Remember to look at the patient’s face during palpation to see if any tenderness is elicited  Palpation Guidelines for palpating the abdomen: 1. Avoid touching tender or painful areas until last, and reassure the patient. 2. Perform light palpation before deep palpation to detect tenderness and superficial masses. 3. Keep in mind that the normal abdomen may be tender, especially in the areas over the Xiphoid, liver, aorta, kidney, gas-filled cecum, sigmoid, and ovaries. 4. Overcome ticklishness and minimize voluntary guarding by asking the patient to perform self- palpation. place the examiner’s hands over the patient’s. after a while, let the fingers glide slowly onto the abdomen.  Palpation Guidelines for palpating the abdomen: 5. Using a warm stethoscope as a palpating instrument. 6. Work with the patient to promote relaxation and minimize voluntary guarding: use the following techniques: - Place a pillow under the patient’s knee’s. - Ask the patient to take, deep breaths through the mouth. - Apply light pressure over the patient’s sternum with the left hand while palpating with the right.  Palpation Perform light palpation: - Light palpation is used to identify areas of tenderness and muscular resistance. - Use the fingertips and compress to a depth of 1 cm in a dipping motion. - Gently lift the fingers and move to the next area. - Begin palpation in a non-tender quadrant. - Note tenderness or guarding.  Palpation Perform light palpation: - Normally; nontender. - Tenderness: observe the patient’s facial expressions and body gestures to determine where tenderness is located. - Tenderness may be due to inflammation, infection, pressure from gaseous distention or ascites, tumors or enlarged organs.  Palpation Perform light palpation: - Guarding: is a tensing or rigidity of the abdominal muscles. - No guarding, abdomen is soft. - Voluntary guarding is observed as a tensing of the abdominal muscles and usually involves the entire abdomen.  Palpation Perform deep palpation: - Palpate deeply in all four quadrants to delineate thoroughly abdominal organs and to detect less obvious masses. - Compress with the palmer surface of the fingers to maximum depth, approximately 5 to 6 cm. - Do not palpate a pulsating midline mass; it may be a dissecting aneurysm, which can rupture under the pressure of palpation. - To assess deeper structures, perform bimanual palpation. Place the dominant hand on top of the other and apply pressure with the top while the bottom hands feels the underlying structures.  Palpation Perform deep palpation: Note tenderness: - Normal (mild) tenderness is possible over the xiphoid, aorta, cecum, sigmoid colon, and ovaries with deep palpation. - Severe tenderness or pain may be related to trauma, peritonitis, infection, tumors or enlarged organs. - Assess masses for location, size (cm), shape, consistency, demarcation, pulsatility, tenderness and mobility.  Palpation Palpate the umbilicus: - Palpate the umbilicus and surrounding area for swellings, bulges or masses. - Umbilicus and surrounding area is free of masses, swellings and bulges. - A soft center of the umbilicus can be a potential for herniation.  Palpation Palpate the aorta: - Use the thumb and first finger or use two hands and palpate deeply in the epigastrium, slightly to the left of midline. - Assess the pulsation of the abdominal aorta. - The normal aorta is approximately 2.5 to 3 cm wide. - A wide, bounding pulse, prominent, laterally pulsating masses above the umbilicus, with an accompanying audible bruit, strongly suggests an aortic aneurysm. Palpation: For abdominal aorta Palpation: For abdominal aorta (to feel both the left and right walls of the aorta).  Palpation Palpate the liver: by bimanually method: - Stand at the patient’s right side and place the left hand under the back at the level of th th the 11 to 12 rib. - Lay the right hand parallel to the right costal margin (or point fingertips toward the patient’s head). - Ask the patient to inhale and compress upward and inward with the fingers.  Palpation: Liver Stand on the patient’s right side. Place the left hand behind the patient’s right side under the 11 th and 12 th rib area. Press upward with the left hand. Place the right hand on the patient’s abdomen wall below where the examiner percussed the liver edge. Palpation of Liver: Alternative Method It is acceptable during palpation of the liver to use both hands to palpate abdomen. You use the fingers of one hand to palpate and the other hand is used to apply pressure to the dorsum of the other hand. Thus the hand you are using to palpate does not need to be used to apply pressure.  Palpation Palpate the liver: by hooking method: - The hooking method is performed by standing to the right of the patient’s chest. - Hook the fingers of both hands over the edge of the right costal margin. - Ask the patient to take a deep breath and pull inward and upward with the fingers. - The liver is usually not palpable, although it may be felt in some thin patients.  Palpation Palpate the liver: by hooking method: - Note consistency: if the lower edge is felt, it should be firm, smooth, and even. - A hard, firm liver may indicate cancer - Nodularity may occur with tumors, metastatic cancer and late cirrhosis.  Palpation Palpate the spleen: - Stand at the patient’s right side, reach over the abdomen with the left arm and place the hand under the posterior lower ribs, pulling up gently. - Place the right hand below the left costal margin with the fingers pointing upward. - Ask the patient to inhale, and press inward and upward. - Ask the patient to turn onto the right side may facilitate splenic palpation by bringing the spleen downward and forward.  Palpation Palpate the spleen: - Not usually palpable at the left costal margin; occasionally the tip is palpable in the presence of low, flat diaphragm with deep diaphragmatic descent on inspiration. - A palpable spleen suggests enlarged. Caution: be gentle in palpating an enlarged spleen. Palpation: Spleen  Palpation Palpate the kidneys: - To palpate the right kidney, support the right posterior flank with the left hand, and place the right hand in the RUQ just below the costal margin at the MCL. - To attempt to capture the kidney, ask the patient to inhale, and compress the fingers deeply during peak inspiration. - Ask the patient to exhale and to hold the breath briefly as the examiner gradually release the pressure of the right hand. - If the examiner have captured the kidney, feel it slip beneath the fingers as it moves back into place.  Palpation Palpate the kidneys: - To palpate the left kidney, reach over and support the left posterior flank with the left hand, and place the right hand in the LUQ. - To attempt to capture the kidney, ask the patient to inhale, and compress the fingers deeply during peak inspiration. - Ask the patient to exhale and to hold the breath briefly as the examiner gradually release the pressure of the right hand. - If the examiner have captured the kidney, feel it slip beneath the fingers as it moves back into place.  Palpation - The kidneys are normally not palpable. - Sometimes the lower pole of the right kidney may be palpable by the capture method because of its lower position. - If palpated, it should feel firm, smooth, rounded and may or may not be slightly tender  Palpation of Kidneys Right kidney (take a deep breath, Left kidney (take a deep breath, capture kidney, exhale, slowly release capture kidney, exhale, slowly kidney. release kidney).  Palpation Palpate the urinary bladder: - Palpate for distended bladder when the patient’s history or other findings warrant (e.g. dull percussion note over the symphysis). - Begin at the symphysis pubis and move upward and outward to estimate its borders. - Normally not palpable. - A distended bladder is palpated as smooth, round and somewhate firm mass, extending as far as the umbilicus. - It may be further validated by dull percussion tones.  Special Abnormal Tests Test for shifting dullness: - The patient should remain supine. - Percuss the flanks from the bed upward toward the umbilicus. - Note the change from dullness to tympany and mark this point. - Turn the patient onto the one side. - Percuss the abdomen from the bed upward. - Mark the level where dullness changes to tympany. - The borders between tympany and dullness  Special Abnormal Tests Fluid wave test: - A second special techniques to test for the presence of ascites. - The patient should remain supine. - You will need assistance with this test. - Ask the patient or an assistance to place the ulnar side of the hand and the lateral side of the forearm firmly along the midline of the abdomen.  Special Abnormal Tests Fluid wave test: - Firmly place the palmer surface of the fingers and hand against one side of the patient’s abdomen. - Use the other hand to tap the opposite side of the abdominal wall. - No fluid wave is transmitted. - Movement of a fluid wave against the resting hand suggests large amounts of fluid are present (ascites).  Special Abnormal Tests Test for Appendicitis: 1. Rebound tenderness: - Abdominal pain and tenderness may indicate peritoneal irritation. - This test for rebound tenderness should always be performed at the end of the examination because a positive response produces pain and muscle spasm that can interfere with the remaining examination.  Special Abnormal Tests Test for Appendicitis: 1. Rebound tenderness: - Palpate deeply in the abdomen where the patient has pain and then suddenly release pressure. - Listen and watch for the patient’s expression of pain. - Ask the patient to describe which hurt more, the pressing in or the releasing, and where on the abdomen the pain occurred.  Special Abnormal Tests Test for Appendicitis: 1. Rebound tenderness: - No rebound tenderness. - Rebound tenderness is present when the patient perceives sharp, stabbing pain as the examiner releases pressure from the abdomen (Blumberg sign). - It suggests peritoneal irritation (as from appendicitis). Inspection 1- Symmetry and Shape (Obvious lumps, swellings) 2- Pulsation and peristalsis 3- Venous distension (capute medusa) 4- Discoloration (Cullen’s/Grey Turners) 5-Position of umbilicus and hernia orifices Auscultation 1-Bowel sounds 2- abdominal Aorta 3- Liver bruits Percussion Liver Spleen Bladder Shifting Dullness (if relevant) Fluid Thrill (if relevant) Palpation Light Palpation – 9 areas Deep Palpation – 9 areas Rebound tenderness Liver Spleen Kidneys Bladder Aorta  Sample Documentation Normal Exam: Abdomen soft, rounded and symmetric without distention; no lesions or scars, or visible peristalsis. Aorta midline without bruit or visible pulsation. Umbilicus inverted and midline without herniation. Bowel sounds present in all 4 quadrants. Liver, kidney and spleen non-palpable; no tenderness on palpation. Reports good appetite; no constipation, nausea or diarrhea. Voiding well and denies laxative use.