Jarvis: Physical Examination & Health Assessment, 1st Canadian Edition

Chapter 21: The Abdomen Instructors Manual ANNOTATED LEARNING OUTCOMES After completing this chapter, the student will do the following: Identify the organs located in each of the four abdominal quadrants The right upper quadrant contains the liver and gallbladder, the duodenum, the head of the pancreas, the right adrenal gland, a portion of the right kidney, the hepatic flexure of the colon, and portions of the ascending and transverse colon. The left upper quadrant contains the left lobe of the liver, the spleen, the stomach, the body of the pancreas, the left adrenal gland, a portion of the left kidney, the splenic flexure of the colon, and portions of the transverse and descending colon. The right lower quadrant contains the lower pole of the right kidney, the cecum and appendix, a portion of the ascending colon, the right ureter, and the right ovary and fallopian tube or right spermatic cord. The left lower quadrant contains the lower pole of the left kidney, the sigmoid colon, a portion of the descending colon, the left ureter, and the left ovary and fallopian tube or left spermatic cord. In addition, several structures lie in the midline, namely, the abdominal aorta, the urinary bladder (if distended), and the uterus (if enlarged). Identify pertinent topics that must be reviewed during the portion of the interview that is related to the abdomen Subjective data obtained from the patient help the examiner identify actual or potential problems related to the gastrointestinal system. As the examiner gains experience, the depth of questioning will be based on the prior responses of the patient. Topics that are of special relevance to the abdomen include nutrition and appetite, ability to chew and swallow foods, food intolerances (or nausea and vomiting), and any pain associated with the abdomen. Questions for identifying bowel habits and the use of any laxatives must be included. The interview must also obtain information regarding any present or past rectal problems and gastrointestinal problems. Because many medications are metabolized by the liver or have gastrointestinal side effects, a review of current medications is also indicated. Use measures that will enhance abdominal wall relaxation If the abdomen is to be assessed accurately, the patient must be relaxed. The bladder must be empty, the room must be at a comfortable temperature, and the patient must be comfortable, with knees supported, arms at the sides, and good lighting and visualization of the entire abdomen. The examiner must make sure the stethoscope end
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piece is warm and that his or her fingernails are short. Painful areas should be examined last to avoid muscle guarding.

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Instructors Manual Use the correct sequence of examining techniques

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The sequence for examining the abdomen is inspection, auscultation, percussion, and palpation. This is done because percussion and palpation can increase peristalsis and might cause a false interpretation of bowel sounds. Interpret findings obtained during inspection of the abdomen Contour, symmetry, the shape of the umbilicus, the condition of the skin on the abdomen, and the presence of pulsations or movement must all be observed during an inspection of the abdomen. The examiner must discriminate between normal and abnormal findings and use the information obtained through inspection as a basis for further exploration if indicated. The pattern of pubic hair growth and the demeanor of the patient should be assessed with the inspection. Interpret findings obtained during auscultation of the abdomen Auscultation of the abdomen is an important nursing assessment, especially for postoperative patients. Although the clicks of a normal bowel can occur from 5 to 30 times per minute, the nurse must listen for up to 5 minutes before deciding that bowel sounds are completely absent. The examiner also must note whether any vascular sounds or bruits are present. Interpret findings obtained during percussion of the abdomen Knowledge of the location of various organs in the abdomen is especially important during percussion. This knowledge will help the examiner relate the sounds that are heard to those that are expected from the organs in the region being percussed. Percussion reveals the relative density of the abdominal contents. Because of air in the intestines, tympany is the predominant sound. Dullness may be heard over a distended bladder, adipose tissue, fluid, or a mass. A change in tone may be noted over the descending colon if there is a need for evacuation. A change from lung resonance to dullness will identify the borders of the liver, which ranges from 6 to 12 cm in width and; in some individuals, an area of splenic dullness 7 cm or less in width may be noted between the ninth to eleventh intercostal space behind the left midaxillary line. Interpret findings obtained during palpation of the abdomen Light and deep palpation provides the examiner with the ability to distinguish normal organs, enlarged organs, abnormal masses, and unusual sensations that are elicited. Incorporate health promotion concepts when performing an assessment of the abdomen

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Measures to promote liver health are discussed. Many behaviors can increase the risk of hepatitis. The three leading causes of hepatitis are hepatitis A, hepatitis B, and hepatitis C infections. Vaccinations are available for both hepatitis A and hepatitis B.

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KEY TERMS anorexia nervosa ascites borborygmus bruit costovertebral angle dysphagia epigastric region fluid wave hematemesis hernia hypogastric/suprapubic region iliopsoas muscle test inspiratory arrest (Murphys sign) melena obturator test pica purging pyrosis rebound tenderness (Blumbergs sign) referred pain shifting dullness succession splash tympany umbilical region viscera

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Instructors Manual TEACHING STRATEGIES

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Obtain two Styrofoam cups with lids. Fill one cup with water or sand; leave the other empty. Have students percuss the tops of the two cups. Although the sounds are exaggerated, it will allow students to learn to differentiate between sounds heard over an air-filled organ and those heard over a solid organ. Using the photographs in the textbook as a guide, have students name the abdominal organs on another student. This exercise can be done in groups of three, with students taking turns in each role: one student is the patient, a second student follows the text, and the third student acts as the examiner. After all students feel knowledgeable, have each locate and name each of the organs from memory. When students are knowledgeable regarding the anatomy and physiology of the abdomen, have them complete an abdominal assessment, using each other as patients. Have students practise palpation using one hand, two hands (bimanual), and the hand of a patient under their own. Have students document the results of the examination completed on a peer. At the end of at least one full abdominal examination, give students half of a piece of paper and ask each to briefly describe the part(s) of the examination for which they most want to have additional practice. Discuss the ways this can be achieved (such as with family members, classmates, and additional patients in the clinical setting. Discuss normal and abnormal findings for an infant, a child, and an older adult. Assign students to take an abdominal history and perform an examination in the clinical setting. In the clinical setting, have students analyze the dietary history and the abdominal assessment findings for an assigned patient. Encourage students to practise on family members of various ages. On slips of paper, write descriptions of the special procedures for advanced practice (i.e., test for rebound tenderness [Blumbergs sign], test for inspiratory arrest [Murphys sign], iliopsoas muscle test; and obturator test). Divide the students into pairs and have one student perform the test, without telling the other student what the test is. See if the patient is able to respond by acting out a positive response to these tests.

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Instructors Manual CRITICAL THINKING EXERCISES

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Application to Clinical Practice For each situation described below, have students discuss the age, socioeconomic, and ethnocultural factors that should be considered during the gathering of subjective and objective data and the provision of health care. In addition, have students relate expected or normal findings to the findings described, discuss any additional information that might be needed before a judgement can be made, and identify at least one relevant nursing diagnosis for any actual or potential problem identified. M.S. has been coming to your health centre for prenatal care. She is in the twentyfourth week of gestation. During this visit, a weight loss of 2.3 kg from the last visit (1 month ago) is noted. M.S. states that she is having more difficulty with constipation and that the morning sickness has not been totally resolved. Bowel sounds are diminished. A.Z., aged 70 years, has come to the health centre for follow-up care of type 2 diabetes, which seems to be well controlled. During the examination, A.Z. states that his wife died 3 months ago; he requests a prescription for sleep medication. Discuss the age-related changes in the gastrointestinal system that must be considered before an appropriate hypnotic can be prescribed. X.M. has come for a follow-up visit for contact dermatitis. Although the dermatitis has responded well to the prescribed treatment, X.M. complains of constipation and asks your opinion about using milk of magnesia for this problem. Is this an appropriate solution for this concern? If not, describe additional information that must be obtained before the problem can be addressed. L.D., aged 16 years, has come in for a high school sports physical examination. The practitioner notes a 6.8 kg weight loss since last year. Menses are absent. P.D. has brought her daughter, aged 18 months, to the family health centre for routine immunizations. She expresses concern about her daughter, stating that she just picks at her food. A.N. is brought to the emergency department by family members. The patient is alert and oriented and states that he just vomited a large quantity of frank blood. His history includes complaints of decreased appetite, back pain, and recent weight loss. He also has a history of fractured vertebrae 5 years ago and smoked two packs of cigarettes a day for 20 years. He is a welder by occupation. History also includes a colon resection 18 months ago for cancer. M.M. has come to the health clinic complaining of fatigue, anorexia, and recent weight loss. He states that he completed an alcohol rehabilitation program 4 years ago after 35 years of alcohol abuse. On examination, sclerae appear jaundiced. B.D. has just returned to the medical/surgical unit after a gastric resection. A nasogastric tube and an IV are in place. The patient is complaining of pain in the

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Instructors Manual incisional area. Morphine sulphate is ordered for pain, and it has been within the prescribed time since the patient was last medicated.

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W.B., a 60-year-old woman, was to have arthroscopic knee surgery, but her hematocrit and hemoglobin (H&H) indicated that she was anemic. Further testing revealed the presence of occult blood in her stool. She is scheduled for a colonoscopy next week and is worried about the possible findings. S.S. brings in her 3-month-old daughter and tells the practitioner that her baby is constipated. She wants to give her small doses of milk of magnesia to help her have bowel movements. E.S., aged 4 years, is in the clinic for a well-child check and school physical. When the nurse tries to examine her abdomen, E.S. giggles and wriggles away from the examiners hands. Im so ticklish! she says.

WEB SITES OF INTEREST Canadian Diabetes Associationhttp://www.diabetes.ca/ Canadian Liver Foundationhttp://www.liver.ca/Home.aspx Canadian Society of Intestinal Researchhttp://www.badgut.com/index.php? contentFile=ulcer_disease&title=Ulcer%20Disease Colorectal Cancer Association of Canadahttp://www.colorectal-cancer.ca/en/ Crohns and Colitis Foundation of Canadahttp://www.ccfc.ca/English/index.html The Kidney Foundation of Canadahttp://www.kidney.ca/ PERFORMANCE CHECKLIST

AbdomenEssential Behaviours Yes Wash hands Provide privacy Explain the procedure to the patient Use a systematic approach Obtain or review history Obtain proper lighting Position the patient Inspect abdomen
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No

Comments

Instructors Manual Contour Symmetry Umbilicus Condition of skin Presence or absence of pulsations or movements Hair distribution Assess the patients demeanor Auscultate abdomen in all four quadrants Presence or absence of bowel sounds Character and frequency of bowel sounds Vascular sounds Percuss abdomen General tympany Liver span Splenic dullness Perform special procedures (if indicated) Fluid wave Shifting dullness Costovertebral angle tenderness Palpate abdomen (light and deep) Bend the patients knees to increase relaxation Instruct the patient to breathe slowly

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Perform light palpation (about 1 cm) in all four quadrants, noting areas of guarding Perform deep palpation (5 to 8 cm) in all four quadrants, noting areas of guarding Palpate Liver Spleen Kidneys Aorta Complete special procedures and checks Rebound tenderness (Blumbergs sign) Inspiratory arrest (Murphys sign) Iliopsoas muscle test
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Instructors Manual Obturator test Identify special considerations Cultural and social Developmental care Health promotion Document findings

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OPEN-BOOK QUIZ Chapter 21: Abdomen Complete the following crossword puzzle.

CLUES Across 2. A reliable sign of peritoneal inflammation, also known as rebound tenderness 6. Organ whose enlargement is termed hepatomegaly 8. Procedure performed after inspection in assessing the abdomen 9. Organ whose inflammation may be indicated by a positive Murphys sign 11. The type of pain that comes from an Down 1. Protrusion of abdominal organs through an abnormal opening in a muscle wall 3. Another word for heartburn 4. Free fluid in the peritoneal cavity 5. Vomiting of blood 7. A craving for nonfoods such as grass,

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Instructors Manual internal organ 12. A loss of appetite for food dirt, or paint chips 10. Muscle test performed when appendicitis is suspected

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