1. Chapter 13 Module I Abdominal and Gastrointestinal System
Amanda Sourvelis, MSN, RN

2. Examination Observe general behavior and position Inspect abdomen for:
Skin color, characteristics, contour
Should be smooth
Striae, scars, faint vascular network
Contour usually sunken
Abdominal Examination
Have the patient to empty their bladder
Position them supine
Observe general behavior and position
Does your patient exhibit any unusual findings such as restlessness, knees drawn up, are they lying very still? Are they rocking back and forth?
Inspect abdomen from side of the bed using a light source
Skin color, surface characteristics, contour, surface movements
Surface characteristics should be
Smooth,
With centrally located umbilicus
Skin color may be ligher because of lack of exposure
Striae, scars, faint vascular network
Contour usually sunken;
Slight protrusion if overweight or obese

3. Examination Auscultate for bowel sounds Auscultate for vascular sounds
Diaphragm of stethoscope
Systematic progression
Auscultate for vascular sounds
Use bell over
Aorta, renal, iliac, femoral arteries
Epigastric area/around umbilicus for venous hum
Examination
Unlike other assessments, the abdominal assessment has a different order
Auscultation follows inspection Why?
So we don’t disrupt normal bowel sounds and cause increases peristalsis, which will give false bowel sounds
Auscultate:
BEFORE palpation and percussion
Auscultate for bowel sounds
Diaphragm of stethoscope lightly …. Why because pushing down will cause peristalsis
Systematic progression begin in the RLQ where bowel sounds are almost always present
Normal bowel sounds should be heard every 5-15 seconds
Borborgmi;prolonged gurgles of hyperperistalis
Bowel sounds may be documented as “ABSENT” after
Listening in ALL four quadrants for
Five minutes in each of the quadrants!
Bowel sounds may be altered or absent with a paralytic ileus. Paralytic ileus: Obstruction of the intestine due to paralysis of the intestinal muscles.
As you listen to the abdomen, Auscultate for vascular sounds especially with people with hypertension
Use bell of stethoscope over
Aorta, renal, iliac, femoral arteries for bruits which occurs with stenosis or occlusion of an artery
Use bell over
Epigastric area/around umbilicus for venous hum is rare and occurs with portal hypertension and cirrhotic liver

4. Examination Percussion
If you suspect distention, fluid, or solid masses.
Note the distribution of tympany and dullness
Expect to hear tympany in most of the abdomen
Expect dullness over the solid abdominal organs such as the liver and spleen.
Tympany loud high pitch drumlike sound

5. Examination Palpate abdomen lightly Palpate abdomen deeply
Tenderness, muscle tone
No tenderness
Palpate painful areas last
Palpate abdomen deeply
Tenderness, masses
Observe for facial grimaces
Ask to breathe slowly through mouth
Examination
Before palpation, ask the patient to bend their knees to relax their abdominal muscles
And breath through their mouth with jaw open, this decreases voluntary guarding.
Palpate all 4 quadrants of the abdomen lightly (1-2cm) with the pads of the fingers for
Tenderness, muscle tone, surface characteristics
No tenderness; Relaxed abdominal muscles
Palpate painful areas last
Watch the patients face for signs of discomfort
Abdominal pain on light palpation suggests peritoneal irritation or inflammation.
Involuntary rigidity (muscle spasm) typically persists despite relaxation maneuvers
Palpate abdomen deeply 4-6cm use one hand on top of the other and slowly push down. if tenderness is known save this area for last on palpation.
There should be no Tenderness, masses
Observe for facial grimaces that indicate areas of tenderness
Ask to breathe slowly through mouth to facilitate muscle relaxation
Also check for rebound tenderness. Choose the sight away from the painful area hold your hand at a 90 degree perpendicular to the abdomen push down slowely and deeply the lift up quickly. A normal response would be negative or no increased pain when hand released. Always perform this test last.

6. Examination: Special Circumstances
Percuss liver span
Palpate around umbilicus
Ring should be round, no bulges
Palpate liver
Examination: Special Circumstances!
Indirect percussion of all quadrants:
Assess density of abdominal contents
Percuss liver span begin in the area of lung resonance and percuss down until the note changes to a dull quality. Mark the spot. Then find abdominal tympany and percuss upward and mark where the tone changes from tympany to dull.
Palpate around umbilicus for bulges, nodules, umbilical ring
Ring should be round, no bulges
Umbilicus inverted or slightly everted
Palpate liver for lower border and tenderness using the hooking technique
Where you stand on the patients righ side place your hands side by side at the right costal margin and curve your fingers to hook them under the costal margin.
Ask the patient to take a deep breath and you may feel the liver bump against your fingers during inspiration. The border should feel smooth with no tenderness.

7. Examination Palpate kidneys for Percuss kidneys for
Presence, contour, tenderness
Percuss kidneys for
Costovertebral angle (CVA) tenderness
Assess abdominal pain
McBurney’s sign
Iliopsoas muscle test
Obturator muscle test
Examination
Page 280 Palpate kidneys for
Presence
Contour
Tenderness
Normally they are not palpable
If your patient reports pain in the back (flank pain), Percuss kidneys for
Costovertebral angle (CVA) tenderness
Patient seated
Direct or indirect
Patient should feel thud, but no pain
Tenderness or pain
Pyelonephritis
Kidney stone
glomerulonephritis
Assess abdominal pain R/T inflammation
Test for rebound tenderness
McBurney’s sign:
Test for appendicitis
Test for Rebound Tenderness
Positive McBurney’s Point: Indicates Appendicitis
Palpate halfway between umbilicus and anterior iliac crest
Press firmly
And release quickly
Absence of pain is negative
Page 284, Figure 13-23
Iliopsoas muscle test:
Page 284, Figure 13-24
Patient supine
Place your hand over lower right thigh
Have pt raise right leg
And flex hip
Nurse to push down on the lower right thigh
Resisting the patient as he/she is raising
If patient
c/o pain RLQ with pressure:
Positive test
Obturator muscle test:
If ruptured appendix or abscess suspected
Have patient supine
Flex right hip to 90 degrees
Nurse to
Hold knee and ankle and
Rotate leg medially and laterally
Test is negative if no pain
If pain in hypogastric region:
Suspect ruptured appendix or pelvic abscess

8. Common Problems and Conditions: Alimentary Tract
Gastroesophageal reflux disease
Gastric secretions into esophagus
Heartburn, regurgitation, dysphagia
Hiatal hernia
Protrusion of stomach
Muscle weakness
Peptic ulcer disease
Duodenal ulcer
Most common
Gastric ulcers
Caused by stress
Problems and Conditions in the Alimentary Tract
Gastroesophageal reflux disease
backFlow of gastric secretions into esophagus
Caused by incompetent lower esophageal sphincter, pyloric stenosis or motility disorder.
Increased intraabdominal pressure
Heartburn, regurgitation, dysphagia difficulty swallowing
Aggravated by lying down
Relieved by sitting up, antacids, eating
Hiatal hernia
A portion of the stomach herniates through the diaphragm and into the thorax.
Herniation results from Muscle weakness R/T
Pregnancy, obesity, ascites
Heartburn, regurgitation, dysphagia, feeling of fullness
Peptic ulcer disease
A peptic ulcer is an ulceration in the mucosal wall of the stomach, pylorus, duodenum or esophagus in portions accessible to gastric secretions
May have gastric, Duodenal ulcer or both
May result from H. pylori infection
Duodenal
most common
Most common; Break in mucosa; Forms scar
Burning pain 2 to 4 hours after eating, midmorning, midafternoon, middle of night; relieved with antacids or eating
Gastric ulcers
Caused by stress; Steroids, aspirin, NSAIDs Burning pain in left epigastrium 1-2 hrs after eating

9. Crohn’s disease
Chronic inflammatory bowel disease (IBD)
Inflammation may occur from mouth to anus
Commonly affects terminal ileum, colon
Fistulas, fissures, abscesses
Abdominal pain, diarrhea, nausea, fever, chills, weakness, anorexia, weight loss

10. Common Problems and Conditions: Alimentary Tract
Ulcerative colitis
May progress to colon cancer
Abdominal pain, weight loss
Profuse bloody diarrhea
Diverticulitis
Herniations through colon wall
Cramping pain, distention
Ulcerative colitis
Starts in rectum, progresses through Large intestines
May progress to colon cancer.
Abdominal pain, fever, anemia, weight loss because of poor absorption of nutrients
Profuse bloody diarrhea with mucus, pus
Remissions and exacerbations.
Diverticulitis
Inflammation of diverticula, herniation's through muscular wall in colon
Cramping pain in the lower left quadrant, N/V, usually constipation
Abdomen distended, decreased bowel sounds
Instruct patient to avoid gas forming foods or those containing seeds or nuts because these can become trapped in the pouches and cause inflammation.

11. Common Problems and Conditions: Hepatobiliary System
Cirrhosis
Chronic degenerative liver disease
Viral hepatitis, alcohol abuse
Ascites, jaundice
Cholecystitis with cholelithiasis
Inflammation of gallbladder (cholecystitis)
With gallstones (cholelithiasis)
Right upper quadrant colicky pain
Radiates to right scapula
Hepatobiliary System
Cirrhosis
Chronic degenerative liver disease
Viral hepatitis, obstruction, alcohol abuse
Ascites ( accumulation of fluid in the peritoneal cavity that results from venous congestion on the hepatic capillaries)
Jaundice: liver is unable to metabolize bilirubin
dark urine, clay-colored stools; End-stage cirrhosis is hepatic encephalopathy and coma
Cholecystitis with cholelithiasis
Inflammation of gallbladder (cholecystitis)
With gallstones (cholelithiasis)
Obstructed bile duct by edema, gallstones
Right upper quadrant colicky pain
Radiates to right scapula
Mild jaundice

12. Common Problems and Conditions: Urinary System
Urinary tract infections:
Urinary bladder (cystitis)
Urethra (urethritis)
Renal pelvis (pyelonephritis)
Gram-negative organisms
Nephrolithiasis
Formation of stones in kidney
Stones, or calculi
Fever, hematuria, flank pain that radiate to groin, genitals
Urinary System
Urinary tract infections:
Urinary bladder (cystitis), urethra (urethritis), renal pelvis (pyelonephritis)
Most from gram-negative organisms
E coli, Klebsiella, Proteus, Pseudomonas
Originate From patient’s GI tract; Urethra to bladder
Symptoms include
Urethritis: Frequency, urgency, dysuria (painful urination)
Cystitis: Above, plus signs of bacteriuria fever more common in women because of their shorter urethra and close to the rectum
Pyelonephritis: Flank pain, dysuria, nocturia, frequency
Nephrolithiasis
Formation of stones in kidney pelvis
Urinary stasis and infection are important variables in the development of the stones.
But also from
diet high in calcium,
vit d, milk, protein,
dehydration,
use of diuretics,
catheters,
immobilization,
elevated uric acid levels such as gout.
Assessment: renal and urethral colic which radiates through the genitals,
sharp severe pain, dull aching pain over kidneys,
nausea vomiting, low grade fever, high numbers of white, red blood cells and bacteria in the urinalysis.
Hematuria. CVA tenderness.
Problems resulting from stones are pain, obstruction, tissue trauma, secondary hemorrhage and infection.
Located through radiography of the kidney, ureters and bladder, ct scanning and renal ultrasound.