Abdominal Assessment

Assessment of GI system

Abdominal regions

·         Four quadrants system

·         nine regions system

·         seven regions system

Four quadrant system- A vertical line from the xiphoid process to the pubic symphysis, and a horizontal line across the umbilicus.

·         Right upper quadrant

·         Left upper quadrant

·         Right lower quadrant

·         Left lower quadrant

Right   upper quadrant: Liver, Gallbladder, Duodenum, Head of pancreas, Right kidney and adrenal, hepatic flexure of colon, Part of ascending and transverse colon.

Left   upper quadrant: Stomach, Spleen, Left lobe of liver, Body of pancreas, Left kidney and adrenal, splenic flexure of colon, Parts of transverse and descending colon.

Right lower quadrant: Cecum, Appendix, Right ovary and tube, Right ureter.

Left lower quadrant: Part of descending colon, Sigmoid colon, Left ovary and tube, Left ureter.

Nine abdominal quadrants:

Equipment’s:

·         Examining light

·         Tape measure

·         Skin marker

·         stethoscope

Preparation: 

·         Patient lie on back, pillow under head, knees slightly flexed.

·         Empty bladder.

·          Short fingernails

·         Warm room.

·         Drape upper chest and legs.

History questions

·         Pain  in abdomen

·         Change  in appetite

·         Chewing  and swallowing problems

·         Heartburn

·         Nausea , vomiting, regurgitation

·         Rectal  bleeding

·         Elimination - constipation & diarrhoea

·         Haemorrhoids

·         Voiding  difficulty

·         Previous  surgery

·         Weight  gain or loss

·         Type  of diet

·         Medications 

Sequence of assessment

·         Inspection

·         Auscultation

·         Percussion

·         Palpation

Inspection: Stand on patient’s right side and inspect from above the abdomen. After sitting or stooping down to look across the abdomen. Asses’ abdominal contour

·         Skin - a. pigmentation

                       b. lesions

                      c. striae

                     d. turgor

                     e. scars

·         Superficial vessels

·         Abdominal striae

·         Hair distribution

·         Umbilicus- position, shape, discharge, signs of inflammation

·         Contour

              a. flat                               

               b. rounded                                       

              c. scaphoid

              d. protuberant (distended)

·         Peristalsis

Inspect-color, texture and integrity	Uniform color, silver white striae / surgical scars	Tense, glittering skin,
Inspect for contour and symmetry	Flat, round /scaphoid	distended
Ask to deep breath and hold	No evidence of enlargement of organs	Hepatomegaly/splenomegaly
Look for the contour	symmetric	distension
If distension present measure the girth	At the level of umbilical's

Abdominal musculature:

Have patient raise head- then examine. Muscle separation, hernias become more apparent

Observe for abdominal  movements assoc. with respiration, peristalsis/aortic pulsation

Respiratory symmetric movement  -visible peristalsis and  aortic pulsation in lean people

Limited peristalsis, visible pulsation, dilated veins, marked aortic pulsation

Auscultation of the abdomen: Warm hands

Bowel sounds- Auscultate with diaphragm. Place the diaphragm at all 4 quadrants. Listen for active bowel sounds- irregular gurgling sounds occurring every 5 to 20 sec.

Light pressure with the stethoscope. Ask when the client last ate. Shortly after or long after eating bowel sounds may normally increase. They are loudest when a meal is long overdue. 4-7 hours after a meal, bowel sounds heard continuously over the ileocecal valve area.  

While the digestive contents from the small intestine empty through the valve into the large intestine. Place the flat disc diaphragm of the stethoscope in each side of the four quadrants of the abdomen over all of the auscultatory sites. Listen for active bowel sounds.

Irregular gurgling noise occurring about every 5 to 20 seconds. The duration of a single sound may range from less than a second to more than several seconds. Normal bowel sounds are described as audible. Alteration sounds are described as absent. Extremely soft and infrequent.

Hyper active or increased i.e.; high pitched, loud rushing sounds that occur frequently (e.g. every 3 seconds) also known as borborygmi. Hyperactive sounds indicate increased intestinal motility associated with diarrhoea, an early bowel obstruction, or the use of laxatives.

AUSCULTATION

·         Normal- 5 to 35 times per minute

·         Hypoactive 4 /min or less

·         Hyperactive 30 or more /min

Bruits

a. aorta

b. renal

c. iliac

Friction rub

For vascular sounds

Use the stethoscope over the aorta, renal arteries, iliac arteries and femoral arteries

Listen for bruits (blowing sound due to restricted blood flow through narrowed vessel)

Auscultation for bruits

To auscultate the splenic site, place the stethoscope over the left lower rib cage in the anterior axillary line, and ask the client to take a deep breath.

To auscultate the liver site, place the stethoscope over the lower right rib cage.

Peritoneal friction Rub- rough, grating sounds like two pieces of leather rubbing each other.

Auscultate the splenic area for rub

Percussion

To determine the size of solid organs and presence of masses, fluid and gas.

Use a systematic pattern: begin in the lower right quadrant, proceed to the upper  right quadrant, the left upper quadrant, and  lower left  quadrant.

Percussion of the abdomen

Percuss the 4 quadrants to determine the presence of tymphany	Tympany over the  stomach and gas filled intestine, dullness over the liver, spleen and  full bladder	Large dull area indicate presence of tumor or fluid
Percuss the liver to determine its size	6 – 12 cm in the mid clavicular line 4-8 cm in the midsternal line	Enlarged size

Percussion of liver

Percussion of the liver to determine the size.

The liver size begins in the right midclavicular line below the level of the umbilicus and proceeds as follows;

·         Percuss upward over tympanic areas until a dull percussion sound indicates the lower liver border. Mark the site with a pencil.

·         Percuss downward at the right midclavicular beginning from an area of lung resonance and progressing downward until a dull percussion sound indicates the upper liver border (usually at the fifth to seventh interspace). Mark this site.

·         Measure the distance between the two marks in centimetres to establish the liver size.

·         Repeat the steps at the midsternal line.

Percussion - If dullness in flanks - check for shifting dullness

If indicated check for fluid wave

Special Abdominal Tests:

Test for shifting dullness

Perform the fluid wave test

Palpation of the abdomen:

Perform light palpation to determine areas of tenderness	No tenderness relaxed abdomen with smooth, consistent tension	Tenderness, hypersensitivity superficial mass, localized areas of increased tension
Perform deep palpation	Tenderness may be present over xiphoid process, cecum,  and  sigmoid colon	Generalized tenderness, mobile or fixed mass.

·         Light palpation to evaluate general condition, nature of any distention, and gross abnormalities and painfulness

·         Deep palpation to detect any organ enlargement, abdominal masses or swellings

Light palpation-

·         Hold the palm of your hand slightly above the client’s abdomen, with your finger’s parallel to the abdomen.

·         Depress the abdominal wall tightly, about 1 cm or to the depth of the subcutaneous tissue, with the pads of your fingers.

·         Move the finger pads in a slight circular motion.

·         Note areas of tenderness or superficial pain, masses and muscle guarding.

·         If the client is excessively ticklish, begin by pressing your hand on top of the client’s hand while pressing lightly. Then slide your hand off the client’s and onto the abdomen to continue the examination.

Deep palpation-

·         Palpate sensitive areas last.

·         Press the distal half of the palmar surface of the fingers of one hand into the abdominal wall. Depress the abdominal wall about 4 to 5 cm.

·         Note masses and structure of underlying contents.

·         If a mass is present, determine its size, location, mobility, contour and consistency and tenderness.

·         Never use deep palpation method over surgical site

Rebound tenderness

With one hand, press slowly and deeply over the area indicated and then lift the hand quickly. If the client does not complain of pain during the deep pressure but indicates pain at the release of the pressure, rebound tenderness is present.  This can indicate peritoneal inflammation

Palpation of liver

·         Stand on the client’s right side.

·         Place your left hand on the posterior thorax at the above 11th or 12th rib.

·         This hand is used push upward and provide support of underlying structures for the subsequent anterior palpation.

·         Place your right hand along the rib cage about a 45 degree angle to the right of the rectus muscle with the fingers pointing toward the rib cage.

·         While the client exhales, exert a gradual and gentle downward and forward pressure beneath the coastal margin until you reach a depth of 4 to 5 cm

·         During expiration, the abdominal wall relaxes, facilitating deep palpation. Maintain your hand position, and ask the client inhale deeply. This makes the liver border descend and moves the liver into palpable Position.

·         While the client inhales, feel the liver border move against hand. It should feel firm and have regular contour.

Palpation of spleen

Aortic pulsation

Palpate with thumb and forefinger of one hand deeply into the upper abdomen just left of midline, if aneurysm suspected do not use deep palpation

Palpation of the bladder

Palpate the area above the symphysis if the client’s history indicates possible urinary retention.

Normal findings: Not palpable.

Document the findings in the client record using forms.

Test for appendicitis: Assess for rebound tenderness and Rovsing’s Sign:

ON BACK Check for renal bruits. Costovertebral angle tenderness

IF ABDOMINAL PAIN- patient will have

Tachypnea

Leaning forward

Murphy’s sign

Rovsing’s   sign

Iliopsoas test

Rules if in abdominal pain

Do not administer pain medications, antispasmodics, anticholinergic, or smooth muscle relaxants before a medical exam- mask pain

Contraindications   for abdominal assessment

Never palpate if suspected appendicitis or dissecting abdominal aortic aneurysm. Never palpate with polycystic kidneys. Do not palpate or percuss transplanted organs.