Guarding indicates discomfort. Be alert to signs of guarding

Guarding indicates discomfort. Be alert to signs of guarding

Rebound tenderness Referred rebound tenderness

Aorta: left of midline, feel for pulsation Liver: nonpalpable Spleen: nonpalpable Gallbladder: non palpable Murphy’s sign: taking a deep breath during palpation, if pain, positive for inflammation Kidneys, two hands, lift with one hand, palpate with other, rt. > lt.

Fluid wave: one hand on midline, other person strikes abdomen to set off wave and feel wave with other hand Illipsoas: pt raises leg from hip and examiner pushes down on the leg Obtruator muscle rotate leg laterally and medially

Abdomen Assessment RNRS210

Objectives Upon completion of this unit, the student will be able to: Name the quadrants of the abdomen and organs found in each quadrant. Select patient information relevant to the present problem data of an abdominal history. Inspect the abdomen for abnormalities. Percuss the abdomen to outline and measure organs.

Objectives Upon completion of this unit, the student will be able to: Auscultate the abdomen for bowel sounds, arterial bruits, and venous hums. Utilize the palpation techniques to describe abdominal structures. Recognize expected findings from an abdominal examination. Record findings from the abdominal examination correctly and completely.

4 Anatomy and Physiology Houses multiple major organs Lined by peritoneal membrane Structures of the abdomen

5 Alimentary Tract 27-foot tube from mouth to anus Parts Esophagus: 10 inches long Stomach Small intestine: 21 feet long Large intestine (colon): 4.5 to 5 feet long

6 Alimentary Tract Functions: Ingest and digest food Absorb nutrients, electrolytes, and water Excrete wastes Peristalsis moves food along tract.

7 Alimentary Tract Esophagus 10-inch collapsible tube Connects pharynx to stomach In chest and abdominal cavities Stomach Flask-shaped, lies transversely In upper abdomen below diaphragm Three sections: fundus, body, and pylorus Secretes HCL and enzymes to break down fats and proteins

8 Alimentary Tract Small intestine Connects stomach to large intestine Three sections coiled in abdominal cavity Duodenum: openings for bile and pancreatic ducts Jejunum Ileum (ileocecal valve prevents backflow)

9 Alimentary Tract Small intestine - continued Completes digestion through action of pancreatic enzymes, bile, and other enzymes Nutrients absorbed through walls into body Surface area enormously increased by circular folds and villi

10 Alimentary Tract Large intestine Connects small intestine to anus Four sections: Cecum: vermiform appendix extends from base Ascending colon Transverse colon Descending colon Sigmoid colon Rectum and anal canal

11 Alimentary Tract Large intestine - continued Functions Water absorption Lubrication of contents from large quantities of alkaline mucus that neutralize acids formed by intestinal bacteria Putrefaction: live bacteria decompose undigested food, unabsorbed amino acids, cell debris, and dead bacteria

12 Liver Four lobes in right upper quadrant Major functions Metabolize fats and carbohydrates Convert amino acids to glucose Synthesize fats from carbohydrates and proteins Store vitamins and iron Detoxify harmful substances Produce antibodies and blood coagulants Synthesize bile Convert waste from fat to water soluble

13 Gallbladder Pear-shaped, sac-like organ about 4 inches long recessed in liver Function Gallbladder concentrates and stores bile (made up of cholesterol, bile salts, and pigments) Bile is released into cystic duct (and common bile duct) and maintains alkaline pH of small intestine to permit emulsification of fats for absorption.

14 Pancreas Located behind and beneath stomach Functions Produces digestive juices Endocrine function produces hormones to regulate body’s level of glucose Insulin (the major anabolic hormone of body) Glucagon

15 Spleen Located in left upper quadrant below kidney Function White pulp (lymphoid tissue) Filters blood Produces lymphocytes and monocytes Red pulp Allows for storage and release of blood

16 Kidneys, Ureters, and Bladder Kidneys, ureters and bladder Kidneys located bilaterally in retroperitoneum and connected to bladder via ureters Functions Rid body of water-soluble waste Produces (endocrine) renin, erythropoietin, and biologically active vitamin D Synthesizes prostaglandins

17 Musculature and Connective Tissues Form and protect the abdominal cavity Rectus abdominis Internal and external obliques Linea alba (contains umbilicus) Inguinal ligament (Poupart ligament)

18 Vasculature Descending aorta Branches Iliac arteries (2), formed from division at about the umbilicus Splenic artery Renal arteries

19 Pregnant Women Abdominal wall muscles stretch and lose tone. Organs are displaced and affect functions. Heartburn results from alkaline reflux from duodenal contents into stomach. Gallstones may result from gallbladder changes that produce cholesterol crystals. Urinary stasis and urgency may occur. Constipation or flatus are more common. Hemorrhoids may result from increased venous pressure.

20 Older Adults Functional abilities of GI tract are affected. Motility slows. Secretion and absorption slow. Digestion decreases. Food tolerances diminished Diminished ability of liver to metabolize certain drugs Delayed gastric emptying Gallstones caused by increase in biliary lipids

21 Review of Related History

22 Questions we ask during Health History related to Abdomen Pain—onset and duration Character—Dull, sharp, burning, gnawing, stabbing, cramping, aching, colicky Location of onset, change in location over time, radiating to another area, superficial or deep Intensity—Use pain related scales: 0-10, Faces, Line, FLACC Associated Symptoms-vomiting, diarrhea, constipation, flatus, belching, jaundice

23 Questions:Indigestion Character: feeling of fullness, heartburn, discomfort, excessive belching, flatus, loss of appetite, severe pain Associated with: food intake, particular foods, eating at particular times of day, amount of food, LMP Onset of symptoms: sudden or gradual Symptoms relieved by: OTC drugs, rest, activity, alternative remedies, prescription drugs

24 Questions: Nausea Associated: Stimuli, time of day, date of LMP, Medication use; Rx or OTC

25 Questions: Emesis Character—including physical description of contents, frequency, duration, and ability to keep food and liquids in stomach Medications LMP Alternative therapies and factors leading to alleviation or exacerbation

26 Questions: Constipation Character, including a physical description of stool. Presence of bright red blood. Black or tarry stools? Pattern of bowel movements. Last bowel movement. Diet—any recent change in diet. Fiber content of usual diet?

27 History of Present Illness Fecal incontinence Character Associated symptoms Related factors Medications

28 Questions: Jaundice If Jaundice present, onset and duration Colors of stools and urine Any association with abdominal pain, diarrhea, constipation Exposure to hepatitis Use of drugs, safe sex practices Occupational exposure

29 Questions: Dysuria Character—frequency of urination, color Associated symptoms—burning, slow stream, frequency, fever Exposure to TB, fungal or viral infections, parasitic infection, bacterial infection

30 Questions: Urinary Frequency Change in usual pattern or volume Association with other symptoms—incontinence, dysuria, urgency, hematuria Change in urinary stream; dribbling Associated with previous surgery, menopause, coughing, sneezing Medications or alternative therapies

31 History of Present Illness Urinary incontinence Character Associated symptoms Medications

32 History of Present Illness Hematuria Character Associated symptoms Alternate possibilities Medications

33 History of Present Illness Chyluria Exposure to parasitic infections Exposure to tuberculosis Medications

34 Past Medical History GI disorders: peptic ulcer, polyps, inflammatory bowel disease, pancreatitis Neurological disorders: MS ALS, CVA Other: Hepatitis, Hepatitis vaccine, Hx blood transfusion, cirrhosis of the liver Previous abdominal or urinary tract surgery, injury/trauma Allergies? Laxatives? Medications? Urinary tract infections—?frequency Major illnesses, cancer, arthritis, kidney disease, cardiac disease

35 Family History Familial Mediterranean fever Gallbladder disease Kidney disease Malabsorption syndrome Hirschsprung disease Familiar colorectal cancer syndromes

36 Personal and Social History Nutrition LMP (first day of last menstrual period) Stressful life events Exposure to infectious diseases Travel history Trauma Use of alcohol and/or drugs Tobacco use

37 Pregnant Women Urinary symptoms Frequency, urgency, burning, dysuria Odor (sign of infection) Abdominal pain Fetal movement Contractions Onset, frequency, duration, intensity Accompanying symptoms; back pain Leakage of fluid Vaginal bleeding

38 Older Adults Urinary symptoms Nocturia, change in stream, incontinence Change in bowel patterns Constipation, diarrhea, incontinence Dietary habits Inclusion of fiber in diet Change in appetite Daily fluid intake

39 Examination and Findings

40 Preparation Good light Full exposure of abdomen Empty bladder Supportive pillows Examination and Findings

41 Nine regions Two horizontal lines Two vertical lines

42 Landmarks Four quadrants Navel at center of horizontal and perpendicular lines Examination and Findings

43 Sequence of Exam Order varies from other systems: Inspect Auscultate Percuss Palpate

44 Inspection Surface characteristics Skin Venous return Lesions and scars Tautness and striae Contour (Interactive Exercise) Location of umbilicus Symmetry Surface motion Examination and Findings

45 Inspection Abdominal distention Causes Fat or Fluid Feces Fetus Flatus Fibroid Full bladder False pregnancy Fatal tumor Types Generalized Below umbilicus Above umbilicus Asymmetric Examination and Findings

46 Movement Motion with respiration Peristaltic waves Pulsation Examination and Findings

47 Auscultation Bowel sounds for motility Character Frequency Vascular sounds indicative of problems Bruits Friction rubs Venous hum Examination and Findings

48 Auscultation of Vascular Sounds Bell, listen in epigastric area & each quadrant for bruits, (Aortic, Renal, Iliac, Femoral Arteries) Listen around the umbilicus for a venous hum Diaphragm – listen over the spleen & liver (Friction rub)

49 Percussion Assess size and density of organs or presence of fluid or air Percuss all four quadrants Tympany over most areas Dullness over areas Detect fluid, air, or masses Gastric air bubbles Ascites Fluid-filled masses Solid masses Examination and Findings

50 Percussion of Liver Span Percuss upward from tympany along right midclavicular line to dullness, to determine lower border of the liver; dullness indicates the bottom margin of the liver--mark Percuss downward along right midclavicular line from lung resonance to dullness to determine the upper border of the liver--mark Liver span is the distance between the two marks MSL 4-8 cm MCL 6-12 cm

51 Percussion of Spleen Begin at left midaxillary line At the lowest intercostal space of the left anterior axillary line before and after the patient takes a deep breath—tympany is normal finding Excessive dullness may indicate enlargement

52 CVA --Costal Vertebral Angle Strong percussion with closed fist at poles of each kidney No tenderness should be noted Left Kidney CVA Right Kidney CVA

53 Palpation Evaluate organs Size Shape Mobility Consistency Tension Evaluate umbilical ring Test abdominal reflexes Examination and Findings

54 Palpation of the Abdomen Used to detect muscle spasms, masses, fluid, and areas of tenderness Use both light and deep palpation in exam Patient remains supine Alert patient to forthcoming pressure from exam

55 Palpation Evaluate organs Size Shape Mobility Consistency Tension Evaluate umbilical ring Test abdominal reflexes Examination and Findings

56 Palpation of the Abdomen Used to detect muscle spasms, masses, fluid, and areas of tenderness Use both light and deep palpation in exam Patient remains supine Alert patient to forthcoming pressure from exam

57 Light Palpation Light systematic palpation of all four quadrants Use palms of hands with fingers extended Depress no more than one cm Abdomen should feel smooth with consistent softness

58 Deep Palpation Use palmar surfaces of hands with fingers extended Palpate all four quadrants Some tenderness during this part of the exam is normal Looking for masses, organ consistency, and delineation of abdominal organs

59 Bimanual Palpation Used as an alternative if deep palpation is difficult because a patient is obese or is providing significant muscular resistance One hand on top of the other technique

60 Abdominal Reflexes Use a reflex hammer or a tongue blade Stroke each quadrant of the abdomen Upper abdominal reflexes by stroking upward Lower abdominal reflexes by stroking downward Expect to see a contraction of the rectus abdominal muscle and a pulling of the umbilicus toward the stroked side

61 Special Techniques Shifting Dullness— Assesses presence of fluid. Patient is side lying. Tympany and dullness are percussed, marking borders. Fluid Wave—Three hands needed. An easily assessed fluid wave indicates ascites. Iliopsoas and Obturator Muscle tests—used if appendicitis is suspected

62 Ascites Detection Percuss for dullness or shifting dullness. Test for fluid wave. Examination and Findings

63 Hernias Assessed using inspection and palpation Ask patient to perform valsalva or raise head up from pillow Abnormal protrusions of abdomen Types: Umbilical, Incisional, Inguinal, Femoral

64 Abdominal Pain Assess Quality of pain Location of pain Facial expression during palpation Appetite Rebound tenderness Iliopsoas muscle test Obturator muscle test Examination and Findings

65 Abdominal Pain Possible causes Appendicitis Cholecystitis Pancreatitis Perforated ulcer Diverticulitis Intestinal obstruction Volvulus Leaking aneurysm Biliary stones Salpingitis Pelvic inflammatory disease Ruptured ovarian cyst Renal calculi Splenic rupture Peritonitis Examination and Findings

66 Abdominal Signs Blumberg Cullen McBurney Romberg-Howship Examination and Findings

67 Pregnant Women Inspect Enlarged abdomen Striae Hemorrhoids Auscultate Diminished bowel sounds Fetal movement (FM) Measure Fundal height Examination and Findings

68 Pregnant Women Palpate Fetal movements Fetal position (Leopold maneuvers) Uterine contractions Examination and Findings

69 Older Adults Inspection Rounded contour Auscultation Gas Palpation Lost muscle tone Altered pain perception Examination and Findings

70 Common Abnormalities

71 Alimentary Tract Acute diarrhea Gastroesophageal reflux disease Irritable bowel syndrome Hiatal hernia with esophagitis Duodenal ulcer Crohn’s disease Ulcerative colitis Stomach cancer Diverticulosis Colon cancer Common Abnormalities

72 Hepatobiliary System Hepatitis Cirrhosis Liver cancer Cholelithiasis Gallbladder cancer Cholecystitis Common Abnormalities

73 Pancreas and Spleen Pancreas Chronic pancreatitis Pancreatic cancer Spleen Laceration/rupture Common Abnormalities

74 Kidneys Glomerulonephritis Hydronephrosis Pyelonephritis Renal abscess Renal calculi Acute renal failure Chronic renal failure Renal artery emboli Malodorous urine Common Abnormalities

75 Pregnant Women Hydramnios Common Abnormalities

76 Older Adults Fecal incontinence Urinary incontinence Common Abnormalities

77 Summary of Examination Inspect the abdomen for the following: Skin characteristics Venous return patterns Symmetry Surface motion

78 Summary of Examination Inspect abdominal muscles as patient raises head to detect presence of the following: Masses Hernia Separation of muscles Auscultate with stethoscope diaphragm for the following: Bowel sounds Friction rubs over liver and spleen

79 Summary of Examination Auscultate with stethoscope diaphragm for the following: Bowel sounds Friction rubs over liver and spleen Auscultate with bell of stethoscope for the following: Venous hums in epigastric area and around umbilicus Bruits over aorta and renal and femoral arteries

80 Summary of Examination Percuss the abdomen for the following: Tone in all four quadrants Liver borders to estimate span Splenic dullness in left midaxillary line Gastric air bubble Lightly palpate in all quadrants for the following: Muscular resistance Tenderness Masses

81 Summary of Examination Deeply palpate all quadrants for the following: Bulges and masses around umbilicus and umbilical ring Liver border in right costal margin Gallbladder below liver margin at lateral border of rectus muscle Spleen in left costal margin Right and left kidneys Aortic pulsation in midline Other masses

82 Summary of Examination Elicit the abdominal reflexes. With patient sitting, percuss left and right costovertebral angles for kidney tenderness.

83 Recording Data Abdomen round and symmetric without distention. No lesions or scars noted. Silver striae noted over lower abdomen. No bruits to iliac or renal arteries. Umbilicus midline. Active bowel sounds x4.

84 Recording Data Percussion of tympany over epigastrum Abdomen soft without tenderness or masses Liver span 8 cm at MCL Unable to palpate spleen, kidneys, gallbladder. Abdominal reflexes intact. No CVA tenderness.

85 Practice, Practice, Practice Complete abdominal examination Inspect Auscultate Percuss Palpate

86 References Seidel, H., Ball, J., & Benedict, G. (2006). Mosby’s Guide to Physical Examination (6th ed.). St. Louis, MO: Elsevier.