Abdominal Assessment* Jerry Carley, RN, MSN, MA, CNE Spring 2010 *an abbreviated review…

Patient Record History & Physical Labs & Dx Diagnostics M.A.RM.A.R. Vital Signs & Graphics Name: I & O Assessments Consults Nurse’s Notes TreatmentsMISC Name: James Hanngge Age: 68 y.o Male Adm: DX: Acute Abdominal Pain Procedure(s): to be Announced / determined James Hanngge Reports DRS Orders Orders

Vital Signs & Graphics TEMPTEMP TEMPTEMP 98.6* 100* 102* PULSEPULSE BP 152/96140/90 110/72 100/6094/56 IOIO WT 98.2 kg 95.6 kg NPO 850 U=180 NG=250 U= 188 NG=450 NPO IV=750 NPO IV=750 U= 140 NG=225 NPO IV= 750 U=120 NG=200

History & Physical This 68 y.o. caucasian male in usual good health until 4 p.m. yesterday, when he reports onset of nausea, vomiting, and diarrhea. Soon thereafter Developed acute diffuse abdominal pain, which he rated at 10/10 in the Emergency department. History of diverticulosis, diverticulitis to which is Non compliant with dietary and other measures. VS: T=101.6*(O) P=110 R= 28 BP 162/116 SaO2=96% RA NEURO: INTACT HEENT= WNL, except some difficulty swallowing Lungs = CTA BILAT CV= s1, s2, (-) JVD regular rhythm; tachycardia 2* pain (?) ABD = BOARDLIKE & TYMPANIC; hypoactive B.S. all 4 quadrants (+) Rebound tenderness, (+) Iliopsoas, (-) Murphy’s MS = INTACT

Dr’s Orders 9/11/ Admit to ward x 2. Diagnosis: Abdominal Pain, R/O Small Bowel Obstruction 3. Activity: Bedrest, Bathroom Privileges Vital Signs: Routine 3.Diet: NPO 4.NG Tube to Low Intermittent Suction 5.I&O 6.IV: D5RL w/ 20 mEq KCl to infuse at 125 mL/hr, continuous 7.Labs: CBC w/Diff; Complete Metabolic Panel; Stool cultures x 3; guiac stools 8.Diagnostics: AAS; CXR 9.Medications: Demerol 100 mg IM q4h, PRN Severe Pain Demerol 50 mg IM q4h PRN Moderate pain J Friendly, MD

So, now I need to do an assessment on this patient, with particular (focused) assessment of the abdomen….

No matter what shape you’re in…

Urinary Bladder Stomach Small Intestines Ascending Colon Transverse Colon Descending Colon Spleen Pancreas Liver Gall Bladder Uterus, Ovaries, Fallopian Tubes Abdominal Aorta Vermiform Appendix THERE’S LOTS OF STUFF IN THERE!!! Ileocecal valve Esophagus

Descriptive Anatomy--Abdomen 4 Abdominal Quadrants (Regions) RUQ LUQ RLQ LLQ Know what organs are found in each quadrant!

Descriptive Anatomy 9 Abdominal Regions Epigastric Right Hypochondriac Left Hypochondriac Right Lumbar Umbilical Right Iliac Hypogastric Left Iliac Left Lumbar

Any break in the peritoneum May lead to peritonitis, which Is life-threatening.

Abdominal Assessment Steps (Slightly) Different Inspect Auscultate Percuss Palpate

Some Causes of Distention Feces, Flatus Fetus Fluid Fibroid tumor Fatal tumor

Bowel Sounds: What’s Normal? Normal bowel sounds are low-to-medium-pitched gurgling noises every seconds; Normal Range= 5-30 b.s. per minute Ileocecal Valve What’s Not? Significant alterations are: absence of any sound* or extremely soft and widely separated sounds ileus increased sounds with high-pitched, loud, rushing sound *Must auscultate each quadrant for 5 minutes to say Bowel Sounds Absent

Percussion Done to detect fluid, gas/distention, and masses (use indirect method) Assessment of the liver span –Percuss liver borders at MCL and MSL Percussion for tympany and dullness: spleen and stomach Fist percussion- to elicit tenderness (usually done at costovertebral angle)

Palpation: The Most Important Part of the Exam Light palpation –Assessment of cutaneous hypersensitivity Deep palpation Bimanual palpation: superimposition of 1 hand, trapping, detection of pulsatile mass

Liver

Spleen usually not palpable turn patient to right side (gravity) with knees flexed Bimanual with left hand on back

Gallbladder & Pancreas Gallbladder - normally not palpable –Murphy’s sign: deep breath on deep palpation, patient with cholecystitis will stop inspiratory movement because of the pain elicited Pancreas - normally not palpable –small and retroperitoneal –masses may be a vague sensation of fullness in the epigastrium

Urinary Bladder and Umbilicus Urinary bladder - normally not palpable unless distended with urine –when distended, smooth, round, tense –percussion can be used to define outline Umbilicus - observe for relationship to skin surface, hernia, inflammation, bleeding

Kidneys Usually not palpable in normal adult Client supine, bimanual technique Indirect percussion of the CVA to elicit tenderness related to the kidney

Special Maneuvers Evaluation of ascites –shifting dullness –fluid wave --Palpation to elicit rebound tenderness --Palpation for abdominal masses: --Note characteristics: consistency, regularity of contour movement with respiration tenderness, and mobility --Sketching it may be useful --Palpable bowel segments

AAA* Aorta –Supine position –Press firmly and deeply in the upper abdomen to left of midline to palpate for abdominal pulsations (normal cm) –If you suspect or if patient has history of AAA, DO NOT palpate *Abdominal Aortic Aneurysm

Shifting Dullness

Abdominal Assessment Inspection Auscultation Percussion Palpation Universal Steps Assess for color, contour, pulsations, umbilicus, others such as rashes, lesions, Masses, scars Take Notes or Document findings 1.Auscultate 4 quadrants For bowel sounds using Stethoscope diaphragm 2. Auscultate abdomen for vascular & other sounds using Stethoscope Bell Normoactive Hypoactive Hyperactive Absent Vascular Sounds Perityoneal friction rub ? Percuss 4 quadrants for tone Tympany, Dullness ? 1.Lightly palpate all 4 quadrants 2.Deep palpation 3.Palpate kidneys 4.Assess for rebound tenderness Femoral Pulses: Palpate & auscultate Document

Conditions associated with Left Upper Quadrant Splenic trauma Pancreatitis Pyloric obstruction

Conditions associated with Right Upper Quadrant (RUQ) Liver hepatitis Acute hepatic congestion Biliary stones, colic Acute cholecystitis Perforated peptic ulcer

Conditions associated with Left Lower Quadrant (LLQ) Ulcerative colitis Colonic diverticulitis

Assessing Abdominal Pain Nature of: burning, cramping, severe cramping, aching, knifelike, radiation of pain Onset of: gradual, acute, loss of consciousness Referred or perceived: shoulders, back, sacrum, beneath shoulder blades, to groin area