Abdominal Assessment

March 24th, 2016

Avery Figliomeni

Step 1: Introduce self to patient, and state what you are going to do

Hi my name is _________, I am here to perform a neurological assessment on you. Just

so you know anything you say to me will be kept confidential and the curtains will
be drawn to ensure your privacy

Step 2: Questions

1. Do you have difficulty swallowing?

 I would ask this question because dysphagia occurs with disorders
of the throat and esophagus

2. Do you have any nausea or vomiting?

 I would ask this question because nausea and vomiting is a
common side effect of many medications, GI disease and
pregnancy

3. Do you smoke or drink alcohol?

 I would ask this question because peptic ulcers occur with the
frequent use of alcohol and tobacco

4. Are you using any over the counter medications?

 I would ask this question because many prescriptions and over the
counter medications can have toxic effects on the liver

5. Do you have any pain in the abdominal area?

 I would ask this question because it could indicate that something
might be wrong with one of the organs

Step 3: Vital Signs- state that this is now when you would perform a set of vital signs

 Pulse
 Respiratory rate
 Oxygen saturation
 Temperature
 Pain
 Blood pressure
Step 4: Inspection

 I’m just going to get you to lift up your shirt for me while I inspect the
abdomen
 I am inspecting the contour, skin colour and condition, and any
pulsations or movement of the abdomen

*The abdomen is symmetrical bilaterally, the contour is flat, the surface of

the skin is smooth and even, with normal skin colour and no discolouration,
and I can see slight pulsations from the aorta. All findings are normal

 Now I am going to get you to lift your head as if you were going to do a
crunch so I can inspect for any hernias (no signs of any hernias)

Step 5: Auscultate

 I am going to do this first because percussion and palpation can

increase peristalsis, which would give a false interpretation of bowel
sounds
 I am going to put the diaphragm of my stethoscope lightly against
your skin and listen to all four quadrants, beginning in the RLQ

*I hear normal, gurgling bowel sounds (if I didn’t hear active bowel sounds I
would listen for 5 minutes to determine that they are absent)

 Now I am going to use the bell of my stethoscope to listen for vascular

sounds or bruit
 First over the aorta, then the renal arteries, iliac arteries, I would also
listen over the femoral arteries, but for the purpose of this exam I will
not

*No vascular sounds or bruit were present which is good

Step 6: Percussion

 I am now going to percuss lightly in all four quadrants to determine

the prevailing amount of tympany and dullness (move clockwise)

*Tympany was predominate but dullness was heard over solid organs which
is normal

Liver Boarder

 I am now going to percuss and measure the height of the liver

 I will percuss superiorly until dullness indicates the liver's border and
mark the spot
 Now I am going to place my stethoscope on the spot and perform a
scratch test to determine the measurement of the liver
 And now I will measure the distance between the two markings

*The liver span was 8 cm, which is a normal finding

Spleen

 I am now going to local the spleen by percussing for a dull note from
the ninth to eleventh intercostal spaces

*Splenic dullness was 7cm

CVA Tenderness

 I am now going to assess the kidney, by placing one hand over the
twelfth rib at the costovertebral angle on the back and then thump
that hand with the ulnar edge of my other fist.
 Just let me know if you have any tenderness

*The patient felt no pain (perform the assessment bilaterally) which means
that there is not inflammation of the kidneys
Step 7: Palpation

Light Palpation
 I am going to start with light palpation to screen for any abnormal masses or
tenderness
 Just let me know if you start to feel uncomfortable
*There was no tenderness or any superficial masses

Deep Palpation
 Now I am going to use deep palpation (about 5cm deep) to search for any
deeper masses
*No masses

Liver
 Now I am going to palpate to feel for the liver
 I am going to place my left hand under your back then place my right hand on
the right upper quadrant with my fingers parallel to the midline
 Can you take a deep breath for me as I push down and under deeply to feel
for your liver?
*I was able to feel the liver boarder and it felt smooth

Kidneys
 Now I am going to feel for your kidneys
 I will start with the left one; can you take a deep breath in and out for me?
*The left kidney was not palpable, which is a normal finding as it sits 1cm higher
than the right kidney and is normally not palpable

 Now I will feel for the right kidney

*The right kidney was palpable and it felt smooth

Rebound Tenderness (Mcburney’s Point)

 Now I will assess rebound tenderness, by pushing down slowly and
deeply into your abdomen, then lift up quickly to test for any pain
 A normal is no pain on release of pressure. A positive test can indicate
appendicitis

*The test was a negative rebound tenderness test because there was no pain
response on the release of pressure

Step 8: Conclude exam and thank your patient for participating and allowing you to
do the assessment on them