PHYSICAL ASSESSMENT OF THE ABDOMEN

Dr. Beverly Fineman Nursing 309

OBJECTIVES

At the end of this class, the student will be able to: Identify landmarks for the abdominal assessment Correctly perform techniques of inspection, auscultation, percussion and palpation Differentiate normal from abnormal findings Document findings

Overview of abdominal structure.

large oval cavity extends from diaphragm to symphysis viscera: solid and hollow

Landmarks for the abdominal examination

four quadrants nine sections bony landmarks muscles

More landmarks

Bony landmarks on the anterior body include: xiphoid process of sternum costal margin, midline, umbilicus, anterior iliac spine, pouparts ligament, superior margin of pubis Posterior landmark costovertebral angle

Abdominal assessment

Preparing the exam room preparing the patient positioning the examiner

Assessment Techniques

inspection skin: color, scars, veins, lesions, umbilicus umbilical hernia, bleeding, inflammation

Continued inspection

contour of the abdomen:flat,rounded, protuberant,scaphoid symmetry enlarged organ masses peristalsis,pulsation,distention

distention
-Definition: unusual stretching of
abdominal wall

note position of umbilicus note portion of abdomen that is distended reasons for distention:flat(obesity), flatus(gas), feces, fluid, fetus(pregnancy or tumor)

Auscultation

Where it occurs in abdominal assessment listening for bowel sounds to assess motility normal sounds abnormal sounds how and where to listen

Auscultation continued

Auscultation performed before palpation and percussion Use diaphragm of stethoscope Listen to bowel sounds Normal sounds are clicks and gurgles, irregular, 5-30 times per minute Influenced by digestion

More on Auscultation

Increased bowel sounds are due to hypermotility of peristalsis Decreased are due to paralytic ileus or peritonitis intestinal obstruction can present with increased or decreased sounds

Additional Sounds

Always listen in hypertensive patient Bruits: Bruits are low pitched, vascular sounds, resembling murmur Caused by partially obstructed artery turbulence Listen in epigastrum and each upper quadrant Listen in costovertebral angle(with patient seated) Listen over aorta, iliac arteries, femoral arteries Arterial insufficiency in legs

PERCUSSION

Assessment technique used to assess size and density of organs in the abdomen Examples: used to measure size of liver or spleen

More on percussion

Used to identify masses Used to identify air in stomach or in bowel Used alone or in conjunction with palpation or to validate palpatory findings Orient yourself to the abdomen by lightly percussing all 4 quadrants for tympany or dullness tympany usually predominates due to gas in the bowel

Percussion Continued

Dullness may be present due to feces or fluid or over organs or a solid mass Develop a specific percussion route and stick to it. To percuss the liver or estimate its size: in right midclavicular line, start below the umbilicus with tympany and percuss upward toward liver dullness. Mark to indicate the liver border

Liver Percussion

In the right midclavicular line, percuss down from lung resonance to liver dullness. This indicates the lower border of the liver Mark this and measure between the two lines This is the height of the liver

More about percussion

Percussion provides most accurate clinical measurement of liver size as a gross measurement

Percussing the spleen

Where is the spleen located? in the curve of the diaphragm just posterior to the left midaxillary line When the spleen enlarges, it does so anteriorly, downward and medially. This will replace the tympany of the stomach and colon with dullness

Tricks to Assessing the Spleen

Percuss in the lowest interspace in the left anterior axillary line for tympany. Ask the patient to take a deep breath and percuss on inspiration. the percussion note should remain tympanic A change to dullness suggest spenomegally This is known as a positive splenic percussion sign

Another trick
Percuss in several directions away from tympany or resonance to dullness outline edges a large dull area suggests splenomegally

Other Findings

To differentiate amongst fat, gas, tumor or ascites: fattympany with scattered areas of dullness gasdistention with tympany tumordullness with tympany ascitesfluid seeks the lowest point in the abdomen. Flanks are dull to percussion with tympanic center. There is a protuberant abdomen with bulging flanks

Assessing for Ascites

With patient lying supine, find tympany in center of abdomen From center of abdomen, percuss outward in several directions to denote dullness To test for shifting dullness, ask patient to turn to one side, then percuss from tympany to dullness fluid will sink to lowest point

More on ascites

Assess for fluid wave Puddle sign

Assessing for kidney tenderness

Find the costovertebral angle This is the angle formed by the lower border of the 12th rib and the transverve processes of the upper lumbar vertebrae Place left hand flat in this area on one side, hit the hand sharply with the fist of the other. Patient will admit to tenderness if present. Repeat on the other side

PALPATION

Used to assess muscle tone, tenderness, fluid, organs May be light or deep Use pads of fingertips in light dipping motions and avoid short jabs

Palpation cont.

To differentiate voluntary from involuntary resistance: rectus muscle will relax with expiration. Palpation is light or deep Deep palpation used to define and delineate organs or abdominal masses. Use palmar surface of fingers and feel in all four quadrants

Deep palpation

If masses are felt, note: location, size, shalpe, consistency, tenderness, pulsations, mobility with respiration or with hand. If patient is obese or rigid, use 2 hands to palpate Place one on top of other and feel with lower hand

The bladder

Bladder percussion is unnecessary unless there is a suspicion of urinary retention Palpate above the symphysis An empty bladder is not palpable

Palpation of the liver

Stand on patients right side Place left hand behind patient parallel to and supporting 11-12th ribs Patient should relax Press your left hand forward and place your right hand on abdomen with fingertips below lower edge liver dullness Press in and up while patient takes deep breath; if palpable, liver should come down

Palpation cont.

Liver hook Kidney: not palpable in normal adult May be able to feel lower right kidney pole in very thin person

The spleen

The spleen is usually not palpable From patients right side, reach over and around under patient with your left hand Place right hand below left costal margin and press in toward spleen. Ask patient to take deep breath---will feel if palpable

Assessing for peritoneal irritation

Ask patient to cough. Palpate lightly with one finger over area of pain produced by cough Test for REBOUND TENDERNESS: press finger in firmly and slowly then quickly withdraw. Rebound tenderness mean the withdrawal has caused the pain--- not the pressure Other: Psoas sign and Obturator sign, cutaneous hyperesthesia

Assessing the Aorta

Press firmly deep in upper abdomen slightly to left of midline. Feel for aortic pulsations Determine width of aorta by pressing deeply on either side of aorta What is the normal width of the aorta? If pulsatile mass is found, feel for femoral pulses which may be dimished.

This concludes the examination of the abdomen

Examination of the anus and rectum

This information is sometimes included with the abdominal assessment and at times with assessment of the male and female genitalia. For our purposes, we are including it here

General Principles

Anal canal is outlet of GI tract 3.8cm long Merges with rectal mucosa @ anorectal junction Sensory nerves in anal area responsible for pain due to trauma

Sphincters

2 concentric layers of muscle that keep anal canal closed Internal sphincter under involuntary control by autonomic nervous system External sphincter surround internal sphincters under voluntary control Intersphincteric groove: palpable separation between internal and external sphincter

MORE THAN YOU WANT TO KNOW:

Anal columns - -folds of mucosa extend vertically from rectum and end in anorectal junction Can be seen with scope Each column contains and artery and vein

hemorrhoids

With increased venous (portal) pressure, vein can enlarge. this is a hemorrhoid or a varicosity External hemorrhoids occur below the anorectal junction itch and bleed with defecation painful and swollen with thrombosis resolve and leave flabby skin top around anal opening.

continued

Internal hemorrhoids originate above anorectal junction covered with mucosa may appear as red mass with pressure (valsalva)