Assessment of the Abdomen

Objectives:
◦Obtain the health history of a patient with an abdominal
complaint,
◦Demonstrate the techniques of
abdominal assessment,
Objectives:
◦Describe assessment techniques of a patient with suspected
appendicitis and ascites, and,
◦Document physical assessment
findings of the abdomen.
HEALTH HISTORY
 Health History
1. Patient Profile - Age, Gender

2. Chief Complaint

3. Past Health History - medical, surgical, allergies, medications,

communicable disease, injuries/accidents, immunizations

4. Family History
 Health History
5. Social History - alcohol use, drug use, travel, history, home & work
environment, hobbies & leisure, economic status

6. Health Maintenance - sleep, diet, exercise, stress manangement,

use of safety devices, health check ups
Chief Complaint
 Pain or Discomfort
◦ Can be a major symptom of GI disease.
◦ Take note of the following:
◦ Character
◦ Duration
◦ Pattern
◦ Frequency
◦ Location
◦ Distribution of referred pain
◦ Time of pain - vary greatly depending on
the underlying cause.
 Types of Abdominal Pain
◦Visceral Pain
- Occurs when hollow abdominal organs such as the intestine
or biliary tree contract unusually or are distended or
stretched.
◦ Visceral Pain
- Varies in quality it may be:
- Gnawing
- Burning
- Cramping
- Aching

When it becomes severe, sweating, pallor,

nausea, vomiting and restlessness may
follow.
◦Parietal Pain
- Originates from inflammation of the parietal peritoneum
called peritonitis.
- Steady, aching pain that is usually more severe than visceral
pain and more precisely localized over the involved structure,
- Aggravated by movement or coughing.
- Patients with parietal pain usually prefer to lie still
◦Referred Pain
- Felt in more distant sites which
are innervated at approximately
the same spinal levels as the
disordered structures
Nausea and Vomiting
 Causes of N/V:

◦ 1. Visceral afferent stimulation (e.g. dysmotility, peritoneal irritation, infections,

hepatobiliary or pancreatic disorders, mechanical obstruction).

◦ 2. CNS disorders (e.g. vestibular disorders, increased intracranial pressure,

infection, psychogenic disorders)

◦ 3. Irritation of the chemoreceptor trigger zone from radiation therapy, systemic

disorders, and antitumor chemotherapy medications
 Change in Bowel Habits and Stool
Characteristics
◦ Change in bowel habits may signal colonic dysfunction or disease.

◦ The characteristics of the stool can vary greatly. Stool is normally light to
dark brown; however, specific disease processes and ingestion of certain
foods and medications may change the appearance of the stool.

◦ Blood in the stool can present in various ways and must be investigated.
(Melena) (Hematochezia)
Change in Bowel Habits and Stool Characteristics
 Food and Medications that alter stool color
Altering Substance Color

Meat protein Dark Brown

Spinach Green
Carrots and Beets Red
Cocoa Dark Red or Brown
Senna Yellow
Bismuth, iron, licorice, and charcoal Black
Barium Milky White
Other common abnormalities in stool characteristics
include:
◦ Bulky, greasy, foamy stools that are foul in odor and may or may not float.
◦ Light-gray or clay-colored stool, caused by decrease or absence of conjugated
bilirubin
◦ Stool with mucous threads or pus that maybe visible on gross inspection of the
stool
◦ Small, dry, rock-hard masses occasionally streaked with blood
◦ Loose, watery stool that may or may not be streaked with blood.
 Diarrhea

• An abnormal increase in the

frequency and liquidity of the
stool or in daily stool weight or
volume.
 Constipation
◦A decrease in the frequency
of stool, or stools that are
hard, dry, and of smaller
volume than normal, may
be associated with anal
discomfort and rectal
bleeding.
Increased Eructation
◦belching; the oral
expression of air
Increased Flatulence
◦increased over patient’s
normal status in passing
excess gas in the rectum
Dysuria
◦painful urination
Nocturia
◦night arousal to void
Urinary Incontinence
◦involuntary leakage of
urine
 PHYSICAL
ASSESSMENT
Abdominal Landmarks
 Organs in the Four Abdominal Quadrants

RIGHT UPPER QUADRANT LEFT UPPER QUADRANT

Liver Left Lobe of the Liver
Gallbladder Stomach
Duodenum Spleen
Head of the Pancreas Upper lobe of Left Kidney
Right Adrenal Gland Pancreas
Upper Lobe of Right Kidney Left Adrenal Gland
Hepatic Flexure of the Colon Splenic Flexure of the Colon
Section of Ascending Colon Section of Transverse Colon
Section of Transverse Colon Section of Descending Colon

RIGHT LOWER QUADRANT LEFT LOWER QUADRANT

Lower Lobe of the Right Kidney Lower Lobe of the Left Kidney
Cecum Sigmoid Colon
Appendix Section of the descending colon
Section of the Ascending Colon Left Ovary
Right Ovary Left Fallopian Tube
Right Fallopian Tube Left Ureter
Right Ureter Left Spermatic Cord
Right Spermatic Cord Part of Uterus
Part of the uterus
• RIGHT HYPOCHONDRIAC • UMBILICAL
- Right Lobe of liver - Omentum
- Part of Duodenum - Mesentery
- Hepatic Flexure of Colon - Lower part of the duodenum
- Upper Half of Right Kidney - Part of Jejunum and ileum
- Suprarenal Gland
• HYPOGASTRIC (PUBIC)
• RIGHT LUMBAR - Ileum
- Ascending Colon - Bladder
- Lower Half of Right Kidney - Uterus
- Part of Duodenum
- Jejunum • LEFT HYPOCHONDRIAC
- Stomach
• RIGHT INGUINAL - Spleen
- Cecum - Tail of Pancreas
- Appendix - Splenic flexure of colon
- Lower end of ileum - Upper half of left kidney
- Right Ureter - Suprarenal Gland
- Right Spermatic Cord
- Right Ovary • LEFT LUMBAR
- Descending Colon
• EPIGASTRIC - Lower Half of left kidney
- Aorta - Part of Jejunum and Ileum
- Pyloric end of stomach
- Part of Duodenum • LEFT INGUINAL
- Pancreas - Sigmoid Colon
- Part of Liver - Left Ureter
- Left Ovary and Left Spermatic Cord
 Tips for Examining the Abdomen
• Ask the client to urinate since an empty bladder makes the assessment comfortable
• Ensure that the room is warm since the client will be exposed
• Make the patient comfortable in the supine position, with the pillow under the head and perhaps under the knees.
• Slide your hand under the low back to see if the patient is relaxed and lying flat on the table
❖ RATIONALE: Arching the back pushes the abdomen forward and tightens the abdominal muscles.
• Ask the patient to keep arms at the sides or folded across the chest.
• In draping the patient, to expose abdomen, place the drape or sheet at the level of the symphysis pubis, then raise the gown
to below the nipple line just above the xiphoid process. The groin should be visible but the genitalia should remain covered.
• Before you begin, ask the patient to point out any areas of pain so that you can examine these areas last.
 Tips of Examining the Abdomen
• Warm your hand and stethoscope. To warm your hands, rub them together or place them under hot water.
• Approach the patient calmly and avoid quick unexpected movements. Avoid having long fingernails which
can scratch or scrape the patient’s skin.
• Stand at the patient’s right side and proceed in a systematic fashion with Inspection, Auscultation, Percussion,
and Palpation.
• Visualize each organ in the region you are examining.
• Watch the patient’s face for any signs of pain or discomfort
• If necessary, distract the patient with conversation or questions. If the patient is frightened or ticklish, begin
with palpation with patient’s hand under yours. After a few moments, slip your hand underneath to palpate
directly.
INSPECTION OF THE
ABDOMEN
• First, observe the general appearance of the patient-lying quietly, writhing with discomfort.
• From the right side of the bed, inspect the surface, contours, and movements of the
abdomen. Watch for bulges, peristalsis. Try to sit or bend down so that you can view the
abdomen properly.
• Inspect the skin integrity.
- Normal Findings : Unblemished skin, uniform color.
- Deviations : Presence of Rash, lesions, Tense, glistening skin (may indicate ascites, edema)
• Also include inspect the skin of the abdomen:
- Temperature – check if the skin is warm, cool or clammy.
- Color – Note any bruises, erythema, or jaundice
- Scars – Describe or diagram their location
- Striae – Old silver striae or stretchmarks are normal
- Dilated Veins – A few veins may be visible normally
◦ Inspect the abdomen for contour and symmetry.
- Observe the abdominal contour while standing at the client’s side when the client is supine
NORMAL: Flat, rounded
DEVIATION: Distended

- Ask the client to take a deep breath and to hold it.

RATIONALE: This makes an enlarged liver or spleen obvious.
NORMAL: No evidence of enlargement of liver or spleen
DEVIATION: Evidence of enlargement of liver or spleen

- Assess the symmetry of contour while standing at the foot of the bed.
Normal: Symmetric Contour
Deviation: Asymmetric contour (localized protrusions around umbilicus, bulging flanks)
◦ Observe abdominal movements associated with respiration, peristalsis,
or aortic pulsations
- For Peristalsis – observe the abdomen for several minutes if you
suspect intestinal obstruction. Normally peristalsis is visible in
very thin individuals.
- For Pulsations – The normal aortic pulsation is frequently visible
in the epigastrium
- Symmetric movements caused by respiration.
Deviations: Limited movement due to pain or disease process. Visible
peristalsis in nonlean clients (Possible bowel obstruction). Marked
aortic pulsation (Abdominal Aortic Aneurysm)
AUSCULTATION OF
THE ABDOMEN
• Auscultation provides important information about bowel motility.
• Auscultate the abdomen before performing percussion or palpation, maneuvers which may alter
the characteristics of the bowel sounds.
• Auscultate the abdomen for bowel sounds, vascular sounds, and peritoneal friction rubs
• Warm the hands and the stethoscope diaphragms.
• Bowel sounds are assessed in all four quadrants using the diaphragm of the stethoscope for high-
pitched and gurgling sounds.
• Ask when the client last ate.
- Rationale: Shortly after or long after eating, bowel sounds may normally increase. They are the
loudest when a meal is long overdue.
• Listen for active bowel sounds – irregular gurgling noises occurring about every 5-20 seconds.
Normal sounds consists of clicks and gurgles, occurring at an estimated frequency of 5-
34 per minute. Hypoactive (one or two sounds in 2 minutes). Hyperactive (five to six
sounds heard in less than 30 seconds)
• Occasionally you may hear the prolonged gurgles of hyperperistalsis from “stomach growling”
called borborygmi.
◦ Auscultating for vascular sounds by using the bell of the stethoscope over the aorta, renal arteries, iliac arteries, and
femoral arteries.
◦ Normal – No arterial Bruits
◦ Deviation – (+) Bruits. May be hypertension or
Atherosclerotic arterial disease.
◦ Auscultating the peritoneal friction rubs: rough, grating sounds like two pieces
of leather rubbing together.
◦ High-pitched and can be heard over the liver and spleen during respiration.
◦ 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. A deep breath
may accentuate the sound of a friction rub area.
◦ To auscultate the liver site, place the stethoscope over the lower right rib cage.
◦ Normal Finding – (-) Friction Rub
◦ Deviations – (+) Friction Rub – present in hepatoma, liver infection, splenic
infarction, pancreatic carcinoma
PERCUSSION OF THE
ABDOMEN
 Why percuss?
◦ Percussion helps you assess the amount and distribution of gas in the abdomen.
◦ Use to assess the size and density of the abdominal organs and to detect the presence of air-filled, fluid-
filled, or solid masses and the size of the liver and spleen.
◦ Percuss the abdomen lightly in all four quadrants to determine the distribution of tympany and dullness.
◦ Tympany usually predominates because of gas in the GI Tract, but scattered areas of dullness from fluid and
feces are also common.
◦ Note any dull areas suggesting an underlying mass or enlarged organ. R: This observation will guide
subsequent palpation
◦ On each side of a protuberant abdomen, note where abdominal tympany changes to dullness of solid
posterior structures
◦ Begin in the lower right quadrant,
proceed to the upper right quadrant,
the upper left quadrant, and the
lower left quadrant..
• Normal:
- Tympany over the stomach and gas-
filled bowels; dullness, especially
over the liver and spleen, or a full
bladder.
• Deviations:
- Large dull areas(associated with
presence of fluid or a tumor)
◦ Percuss the liver to determine its size. Begin in the right
midclavicular line below the umbilicus and proceed as
follows:
❑ Percuss upward over tympanic areas until a dull
percussion sound indicates the lower liver border. Mark
the site with a skin-marking pencil.
❑ Then percuss downward at the right midclavicular line,
beginning from an area of lung resonance and progressing
downward until a dull percussion sound indicated the
upper liver border. (usually at the 5th – 7th intercostal
space) mark this site.
❑ Measure the distance between two marks (upper and
lower liver border) in Centimeters to establish the liver
span or size
❑ Repeat steps 1 to 3 at the mid sternal line

❑ Normal Liver Span

- 4-8 cm midsternal line
- 6-12cm right midclavicular line
PALPATION OF THE
ABDOMEN
LIGHT PALPATION
• Gentle palpation aids detection of abdominal tenderness, muscular resistance, and some
superficial organs and masses. It also reassures and relaxes the patient.
• Perform light palpation, systematically explore all 4 quadrants.
• Ensure that the client’s position is appropriate for relaxation of the abdominal muscles, and warm
the hands.
Rationale : Cold hands can elicit muscle tension and thus impede palpatory evaluation.
• Keeping your hand and forearm on a horizontal plane, with fingers together and flat on the
abdominal wall.
• Palpate the abdomen with a light gentle dipping motion, while the finger pads move in a circular
motion.
• As you move your hand to different quadrants, raise it just off the skin. Gliding smoothly, palpate
in all 4 quadrants.
• Note areas of tenderness or superficial pain, masses, and muscle guarding.
• To determine areas of tenderness, ask the client to tell you about them and watch for changes in
the client’s facial expressions.
• If the client is ticklish (refer to tips on assessing the abdomen)
◦ Palpate after asking the patient to exhale, which usually relaxes the abdominal
muscles.
◦ Ask the client to mouth-breath with the jaws wide open.

◦ Normal : No tenderness, relaxed abdomen with smooth, consistent tension.

◦ Deviations: Tenderness, superficial masses, localized areas of increased tension,
involuntary rigidity typically persists despite the maneuvers, suggesting peritoneal
inflammation.
DEEP PALPATION
❖ Deep palpation is usually required to delineate the liver edge, the kidneys, and abdominal masses.
◦ Perform deep palpation over all four quadrants
◦ Using the palmar surfaces of your fingers, press down in all four quadrants. Press the distal half of the
palmar surface of the fingers of one hand into abdominal wall.
◦ Palpate sensitive areas last
◦ Depress the abdominal wall about 4-5cm
◦ Identify any masses; their location, size, shape, consistency, tenderness, pulsations, and any mobility with
respiration or pressure from the examining hand.
◦ NORMAL : Tenderness may be present near xiphoid process, over cecum, and over sigmoid colon
◦ DEVIATION: Generalized or localized areas of tenderness, mobile and fixed masses

◦ ABDOMINAL MASSES may be categorized in several ways:

◦ Physiologic – pregnancy
◦ Inflammatory – Diverticulitis
◦ Vascular – Abdominal aortic aneurysm
◦ Obstructive – dilated loop or distended bladder
 Signs of Peritonitis
◦ Guarding – a voluntary contraction of the
abdominal wall, often accompanied by a grimace
face that may diminish when the patient is
distracted.
◦ Rigidity – an involuntary reflex contraction of
the abdominal wall from the peritoneal
inflammation that persists over several
examination
◦ (+)Rebound tenderness
PALPATION OF THE
LIVER
◦ Stand at the right side of the client
◦ Place your left hand behind the patient, parallel to and
supporting the right 11th and 12th ribs and adjacent soft tissues
below. Remind the patient to relax on your hand. By pressing
your left hand upward, the patient’s liver may be felt more easily
by your examining hand during anterior palpation.
◦ Place your right hand on the patient’s right abdomen lateral to
the rectus muscle, with your fingertips well below the lower
border of liver dullness (during percussion).
◦ While the client exhales, exert a gradual and gentle downward
and forward pressure beneath the costal margin. During
expiration, abdominal muscle relaxes facilitating deep palpation.
◦ Maintain your hand position, and ask the client to inhale deeply.
This makes the liver border descend and moves the liver border
descend and moves the liver into palpable position.
◦ While the client inhales, feel the liver border, mover against
your hand. On inspiration, the liver is palpable about 3cm
below the right costal margin in the midclavicular line.
◦ It should feel firm and have regular contour. Soft, sharp and
regular smooth surface. Not Enlarged, tender, hard or
nodular
 How to palpate liver if the patient is obese?

◦ HOOKING TECHNIQUE
- Stand to the right of the patient’s chest.
- Place both hands, side by side, on the right of the
abdomen below the border of liver dullness.
- Press in with your fingers and up toward the
costal margin.
- Ask the patient to take a deep breath.
- The liver edge is palpable with fingerpads of
both hands
PALPATION OF THE
SPLEEN
◦ To enhance relaxation of the abdominal wall, the
patient should keep arms at the sides and, if
needed, flex the neck and legs.
◦ With your left hand, reach over the patient to
support and press forward the lower left rib cage
and adjacent soft tissue.
◦ With your right hand below the left costal margin,
press in toward the spleen.
◦ Begin palpation low enough so that you can detect
an enlarged spleen.
◦ Ask the patient to take a deep breath and try to feel
the tip or edge of the spleen as it comes down to
your fingertips.
◦ Note any tenderness, assess the contour, and
measure the distance between the spleen’s lowest
point and the left costal margin.
◦ Repeat with the patient lying on
the right side with legs
somewhat flexed at the hips
and knees.
Rationale: In this position,
gravity may bring the spleen
forward and to the right into
palpable location.
PALPATION OF THE
BLADDER
◦ Palpate the area above the
pubic symphysis if the client’s
history indicates possible
urinary retention.
 LIFESPAN
CONSIDERATIONS
 Infants
◦ Internal organs of newborns and
infants are proportionately larger
than those of older children and
adults, so their abdomens are
rounded and tend to protrude.
◦ Umbilical hernias may be present at
birth.
 Children
◦ Toddlers have characteristic “pot belly” appearance,
which can persist until age 3 to 4.
◦ Late preschool and school-age children are leaner and
have a flat abdomen.
◦ Peristaltic waves may be more visible than in adults.
◦ Children may not be able to pinpoint areas of
tenderness; by observing facial expressions the
examiner can determine areas of maximum
tenderness.
◦ If the child is ticklish, guarding or fearful, use a task
that requires concentration to distact the child, or have
the child place his/her hands on yours as you palpate
the abdomen.
 Elders
◦ The rounded abdomens of elders are due to an
increase adipose tissue and a decrease muscle
tone.
◦ The abdominal wall is slacker and thinner,
making palpation easier and more accurate than
in younger clients. Muscle wasting and loss of
fibroconnective tissue occur.
◦ The pain threshold in elders is often higher;
major problems such as appendicitis or other
acute emergencies may therefore go undetected