Chapter 18 Abdomen

Competencies Identify the physiological function of the abdominal organs. Obtain the health history of a patient with an abdominal complaint. Demonstrate the techniques of abdominal examination. (continues)

Competencies Relate abnormal physical examination findings to pathological processes. Describe examination techniques of a patient with suspected appendicitis and ascites. Document physical examination findings of the abdomen.

Anatomy and Physiology Abdominal cavity Peritoneum Abdominal vasculature (continues)

Anatomy and Physiology Nine abdominal regions Abdominal quadrants Right upper Left upper Right lower Left lower (continues)

Anatomy and Physiology Stomach Small intestine Large intestine Liver Gallbladder Pancreas Spleen (continues)

Anatomy and Physiology Vermiform appendix Kidneys, ureters, and bladder Lymph nodes

Health History Patient profile Age Gender Child to young adult: appendicitis Adult: peptic ulcers, cholecystitis, diabetes mellitus, GI cancers Gender Female: gallbladder disease, mittelschmerz, celiac disease Male: GI cancers, cirrhosis, duodenal ulcers, diverticulosis

Common Chief Complaints Nausea and vomiting Diarrhea or constipation Abdominal pain Hoarseness (continues)

Common Chief Complaints Increased flatulence Dysuria Nocturia Urinary incontinence

Characteristics of Chief Complaint Quality Quantity Associated manifestations Aggravating factors (continues)

Characteristics of Chief Complaint Alleviating factors Setting Timing

Past Health History Medical history Surgical history Allergies Abdomen specific Non-abdomen specific Surgical history Abdominal or urinary procedures Allergies (continues)

Past Health History Medications Communicable diseases Injuries and accidents Immunizations Hepatitis A and B vaccines

Family Health History Malignancies of stomach, liver, pancreas, colon Peptic ulcer disease, diabetes mellitus, irritable bowel syndrome, malabsorption syndromes

Social History Alcohol use Drug use Travel history (continues)

Social History Home and work environments Hobbies and leisure activities Economic status

Health Maintenance Activities Sleep Diet Avoid foods that exacerbate abdominal distress Exercise Stress management (continues)

Health Maintenance Activities Use of safety devices Health checkups Blood chemistry and count Liver function tests Urinalysis Stool guaiac Colonoscopy

Differentiating Abdominal Pain Visceral Parietal Referred

Examination of the Abdomen Equipment Order Inspection Auscultation Percussion Palpation

General Approach to Abdominal Examination Greet patient and explain examination Ensure room is warm, comfortable, and quiet (continues)

General Approach to Abdominal Examination Ask patient to void and save the sample (if indicated) Drape patient to maintain privacy Ask patient to point to tender areas

Inspection Contour Symmetry Rectus abdominis muscles Pigmentation and color (continues)

Inspection Scars Striae Respiratory movement Masses or nodules (continues)

Inspection Visible peristalsis Pulsation Umbilicus

Inspection: Normal Findings Abdomen is flat or round, symmetrical Uniform in color and pigmentation No scars or striae present No respiratory retractions (continues)

Inspection: Normal Findings No masses or nodules Ripples of peristalsis may be visible Non-exaggerated pulsation of the abdominal aorta may be present Umbilicus is depressed

Auscultation Bowel sounds Vascular sounds Venous hum Friction rub Assess all four quadrants Listen for at least five minutes before concluding bowel sounds are absent Vascular sounds Venous hum Friction rub

Auscultation: Normal Findings Bowel sounds Are heard in all quadrants Usually are high-pitched Occur 5 to 30 times per minute Vascular sounds: no audible bruits No venous hum No friction rub

Auscultation: Abnormal Findings Absent, hypoactive, or hyperactive bowel sounds Pathophysiological indications Absent and hypoactive bowel sounds may indicate decreased motility and possible obstruction Hyperactive bowel sounds indicate increased motility and possible diarrhea, gastroenteritis

Examining Patients with Abdominal Drains or Tubes Types: Drainage or feeding Examine Location of drain or tube Condition of skin around the tube insertion site Amount, color, consistency, odor of drainage (continues)

Examining Patients with Abdominal Drains or Tubes Examine (cont’d) Amount of suction (mm Hg) Type of suction (continuous, intermittent) Amount of residual for tube feedings

Percussion Percuss all four quadrants Begin in RLQ, move up to RUQ, move over to LUQ, move down to LLQ (continues)

Percussion Assess liver span, liver descent, margins of spleen, stomach, kidneys, liver, bladder Sounds heard: tympany or dullness

Percussion: Normal Findings Tympany heard over air-filled areas, such as stomach and intestines Dullness heard over solid areas, such as liver or a distended bladder (continues)

Percussion: Normal Findings No tenderness elicited over kidneys and liver Empty bladder is not percussable above the symphysis pubis

Percussion: Abnormal Findings Dullness over areas where tympany is normally heard May indicate a mass or tumor, pregnancy, ascites, full intestine Liver span > 12 cm or < 6 cm May indicate hepatomegaly or cirrhosis (continues)

Percussion: Abnormal Findings Liver descent > 2 to 3 cm May indicate hepatomegaly or cirrhosis Spleen dullness > 8 cm line May indicate splenic enlargement Costovertebral angle tenderness May indicate pyelonephritis (continues)

Percussion: Abnormal Findings Ability to percuss a recently emptied bladder May indicate urinary retention

Palpation Light vs. deep Palpate all quadrants Never palpate over areas where bruits are auscultated Normal findings No tenderness Smooth with consistent softness No muscle guarding

Palpation: Abnormal Findings Tenderness on palpation May indicate inflammation, masses, or enlarged organs Muscle guarding on expiration May indicate peritonitis (continues)

Palpation: Abnormal Findings Presence of masses, bulges, or swelling May indicate enlarged organs, cholecystitis, hepatitis, cirrhosis (continues)

Palpation: Abnormal Findings Liver is palpable below costal margin May indicate CHF, hepatitis, cirrhosis, hepatic encephalopathy, cancer Spleen is palpable May indicate inflammation, CHF, cancer, cirrhosis, mononucleosis (continues)

Palpation: Abnormal Findings Kidneys are palpable May indicate hydronephrosis, neoplasms, polycystic kidney disease Aorta width > 4 cm May indicate abdominal aortic aneurysm (continues)

Palpation: Abnormal Findings Able to palpate recently emptied bladder May indicate urinary retention Palpable inguinal lymph nodes > 1 cm in diameter or tender May indicate systemic infections, cancer

Advanced Techniques Liver scratch test Assessing for ascites Fluid wave Murphy’s sign Rebound tenderness (continues)

Advanced Techniques Rovsing’s sign Cutaneous hypersensitivity Iliopsoas muscle test Obturator muscle test Ballottement