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

2. 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

3. 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

4. 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

5. 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.

6. Inspection: Distended Abdomen
Ascites

7. 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.

8. 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

9. 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

10. 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
·    

11. CVA – Costovertebral Angle
CVA tenderness – positive in pyelonephritis.

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

13. 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

14. 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

15. 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

16. 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.