ASSESSMENT OF THE ABDOMEN Rachel S. Natividad, RN,MSN, NP

ANATOMY RUQ – liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of colon, ascending /transverse colon, right kidney LUQ – stomach, spleen, body of pancreas, left kidney, splenic flexure of colon, transverse/descending colon RLQ – cecum, appendix, right ovary, tube, ureter, and spermatic cord Midline – aorta, uterus, bladder Epigastric, umbilical, suprapubic Abdominal Quadrants

Abdominal Regions Abdominal wall is divided into four quadrants Terms to know: Epigastric-area between the costal margins Umbilical- area around umbilicus Suprapubic- area above the pubic bone Hypochondriac – pertaining to below the cartilage (chondri)/ac Iliac – surrounding the iliac spine

A Different Sequence of Assessment Inspect Auscultate Percuss Palpate Palpating the abdomen before you auscultate can change the character of the patient’s bowel sounds and lead to an inaccurate assessment. Perform the assessment in a private, quiet, warm and well-lit room. Warm your hand and stethoscope before touching the patient. Sounds, masses, tenderness Divide into four quadrants: RUQ, RLQ, LUQ, LLQ Inspect then auscultate Bowel sounds: absent, hypoactive, hyperactive Listen continuously for 5 minutes to determine absence Palpate and/or percuss after listening Abdomen should be soft, non-tender, non-distended

ASSESSMENT Inspection: ·Contour flat round Scaphoid Protuberant distended  Assure privacy and explain exam Warm environment, hands, and stethoscope Drape patient Have patient empty bladder Position patient supine with knees slightly flexed Note the abdominal shape and contour. The abdomen should be flat to rounded in people of average weight. A protruding abdomen may be due to obesity, pregnancy, ascites, or abdominal distention. A slender person may have a slightly concave abdomen Lesions – benign, scars from sx or trauma, striae, etc.  Distention - can be from fluid, air, mass, or obstruction ·     Pulsations - or movement of abdominal wall from peristalsis, pulsations and respiratory movement usually waves of peristalsis can’t be seen. If visible, look like slight wavelike motions. Visible rippling waves may indicate bowel obstruction and should be reported immediately. In thin pts, abd aoritc pulsations may be seen in the epigastric area. (marked pulsations there may indicate HTN. Aortic insuff, AAA, or othe rcondition causin gwidening pulse pressure) Observe the abdomen for symmetry, checking for bumps, bulges, or masses. A bulge may indicate bladder distention or hernia. Have pt raise his head and shoulders, his umbilicus protrudes, he may have umbilical hernia, The skin should be smooth and uniform in color.

Inspection: Distended Abdomen Ascites

Inspection: Skin – lesions, color, texture, scars, venous pattern, striae Striae or stretch marks can result from pregnancy, escessive weight gain, or ascites. New striae are pink or blue, old ones are silvery white.

Auscultation of Bowel Sounds Absent no BS for 5 min Hypoactive less than 5/min Active 5-30 per min Hyperactive > 30 /min BOWEL SOUNDS VENOUS HUMS RENAL BRUITS INGUINAL BRUITS Use diaphragm of stethoscope lightly on skin to prevent stimulating bowel sounds Start in RLQ (BS often present here) then proceed all four quadrants Listen for 3-5 minutes Note character and frequency of BS Normal BS – gurgling, high-pitched sounds, average of 5-30/min Hypoactive BS – less than 5/min; may indicate decreased mobility due to peritonitis, paralytic ileus from abdominal surgery, or from late bowel obstruction Absent BS - no BS for 5 minutes. Hyperactive BS - “borborygmi” loud gurgling sounds Lightly place steth on the RLQ, slighly below the right of the umbilicus. Auscultate in a clockwise fashion in each four quadrants. Spending at lest 2 minutes in each area. Normal BS are high-oitched, gurgling noises caused be air mixing with fluid during peristalsis. The noises vary in frequency and pitch, and intensity. They are loudest before meal times. Normal BS – 5-30 per minute Borborygmus, or stomach growling – are the loud, gurgling, splashing bowel sound heard over the large intesting as gas passes through it. ;; hyperactive BS - > 30 /min – loud, high pitch, tinkling that occur frequently – may occur with diarrhea, constipation, and laxative use hypoactive < 5 per min; - occur infrequently – assoc. with bowel obstruction, ileus, peritonitis, and indicate diminished peristalsis. (paralytic ileus, use of narc meds can decrease peristalsis) absent, no BS for 5 minutes. Be sure to allow enough time for listing in each quadrant before you decide tht bowel sounds are absent. If NGT to suction, turn off suction as to not obscure or mimic sounds

Auscultation: vascular sounds Note vascular sounds – presence of bruits over aorta, renal, iliac, femoral Normally no bruits noted Bruit?? Venous hum & peritoneal friction rub are rare Abdominal aortic aneurysm – surg emerg.-tx immed to prevent hemorrhage, shock, and death If you see bounding pulsation on abd wall, fell for pulsations, and measure (greater than 6 cm- most likely aneurysm) report. Aneurysm

Percussion · Tympany – predominantly over the abdomen – gas-filled ·     Dull - over organs in the abdominal cavity (liver, spleen) CVA tenderness- kidney infection To assess density of abdominal contents, locate organs, and screen for abnormal fluid or masses ·    

CVA – Costovertebral Angle CVA tenderness – positive in pyelonephritis.

Palpate all quadrants Start with rlq or palpate tender areas last – if tender in rlq, then do not begin there.

Palpation Light Palpation Tenderness, Masses, Deep Palpation Rigidity Deep Palpation Tenderness, Masses, Enlarged organs Palpate all four quadrants: To check for muscle resistance or rigidity; masses, fluid, tenderness. To palpate, put finger of one hand close together and make gentle rotating movements as you depress ½ inch (1.3 cm) Light palpation – depress 1 cm:Relaxation; Tenderness; Masses    Palpate areas of pain and tenderness last    May need to distract patient Normal: the abd should be soft and nontender. As you palpate, note any Abnormal findings: tenderness, masses, and rigidity Determine whether resistance is due to patient’s being cold, tense, or ticklish or whether its from muscle guarding or rigidity from muscle spasms or peritoneal inflammation. Deep palpation - depress 5-8 cm; that’s about 2-3 inches. In obese, patient, put one hand over the other and push down. Palpate the entire abd on a clockwise direction and not any: Tenderness;  Masses; Enlarged organs

Normally Palpable Structures Normally palpable structuresKnow what is underneath so you can determine what . E.g. suprapubic distention, full bladder or tumor? Sigmoid colon, stool can be palpated there Liver – should not be able to palpate liver way below the rib = enlarged

Assessment Guide: Elimination Abdomen Inspection: flat, round, obese, concave, distended Auscultation: BS active on all quadrants, no vascular sounds Palpation: soft, nontender; firm and tender on RLQ

Urine: describe – clear yellow; dark amber with sediments Bowel Sounds: skip Flatus: present, none Stool: large amount, brown formed stool Date LBM: 3/3 Med List: Dulcolax, Lomotil, MOM, etc.