Abdominal Assessment Chapter 21- Test 3

Right lower quadrant (RLQ)

-Cecum -Appendix -Right ovary and tube -Right ureter -Right spermatic cord

Subjective Data

-Change in Appetite -Usual weight or changes in weight -Difficulty swallowing -Intolerances to foods & Nutritional -Assessment -Nausea/Vomiting (emesis) -Indigestion -Heartburn (pyrosis) or Belching (eructation) -Medication usage ie. Antacids, bowel stimulators -Bloating or feelings of fullness before or after eating Pain: location, intensity, duration -ETOH use.Cig use FMH: GERD, Colon Ca, Peptic Ulcer, stomach Ca, Urinary hx: Kidney Stones, Bladder Ca -PMH: GI ulcerations, hepatitis, appendicitis, colitis, hernia, Surgical procedures in past Diagnostics: Xrays, Colonoscopy, FOBT -Bowel Activity: Color, consistency, Recent changes, increased use of laxatives -Referred Pain

Developmental: Adults

-Changes in dentition -Reduced saliva, stomach acid, gastric motility, and peristalsis -Fat accumulates in the lower abdomen in women and around the waist in men -The liver becomes smaller and liver function declines -Older adults have a diminished response to painful stimuli

Physical Exam Preparation

-Good lighting, warm room, supine, enhance relaxation and comfort -Expose abdomen by telling pt to put their knees up and have their arms at side

Right Upper Quadrant (RUQ)

-Liver -Gallbladder -Duodenum -Head of pancreas -Right kidney and adrenal gland -Hepatic flexure of colon -Part of ascending and transverse colon

Other landmarks:

-Midline: uterus (if enlarged), bladder (if distended), and left of midline is the aorta, -Epigastric: area between costal margins -Suprapubic: area above the pubic bone -Umbilical: area around the umbilicus

Infant Subjective Specific Questions

Are you breastfeeding or bottle-feeding your infant? If bottle-feeding, how does infant tolerate formula? How does infant tolerate new foods?

Left lower quadrant (LLQ)

-Part of descending colon -Sigmoid colon -Left ovary and tube -Left ureter -Left spermatic cord

Left Upper Quadrant (LUQ)

-Stomach -Spleen -Left lobe of liver -Body of pancreas -Left kidney and adrenal gland -Splenic flexure of colon -Part of transverse and descending colon

Incisional hernia

-a bulge near an old operative scar that many not show when a person is supine but is apparent when the person increases intra-abdominal pressure by a sit-up, by standing, or by the Valsalva maneuver

Inspect the Abdomen: Demeanor

-a comfortable person is relaxed quietly on the examining table and has a benign facial expression and slow, even resp -Abnormal findings: restlessness and constant turning to find comfort occur with the colicky pain of gastroenteritis or bowel obstrctuin; absolute stillness, resisting any movement, occurs with the pain of peritonitis; knees flexed up, facial grimacing, and rapid, uneven resp. also indicate pain

Diastasis Recti

-a midline longitudinal ridge that is a separation of the abdominal recuts muscles -ridge is revealed when intraabdominal pressure is increased by raising head while supine -occurs congenitally and as long as a result of pregnancy or marked obesity in which prolonged distention or a decrease in muscle tone has occurred -it is not clinically significant

Umbilical Hernia

-a soft-skin ocnvered mass, the protrusion of the momentum or intestine through a weakness or incomplete closure in the umbilical ring -it is accented by increased intra-abdominal pressure as with crying, coughing, vomiting, or straining; but the bowerl rarely incarcerates or strangulates -more common in premature infants -most resolve by 1 year; patterns should avoid affixing a belt or coin at the hernia bc this will not help closure and ma cause contact dermatitis -in an adult it occurs with pregnancy, chronic ascites, or chronic intrathoracic pressure (like asthma, chronic bronchitis)

Hooking technique

-an alternative method of palpating the liver is to stand up at the person's shoulder and swivel your body to the right so you face the person's feel -hood you fingers over the costal margin from above and ask the pt to take a deep breath and try to feel the liver edge bump your fingertips

Special Procedures for Advanced Practice: Rebound Tenderness (Blumberg Sign)

-assess rebound tenderness when the pt reports abdominal pain or when you elicit tenderness during palpation -chose a site away from the panful area -hold your hand 90 degrees amor perpendicular to the abdomen and push down slowly and deeply then left up quickly; this makes structures that are indented by palpation rebound suddenly -a normal negative response is no pain on real of pressure -do this test at end of exam bc it can cause severe pain and muscle rigidity -Abnormal findings: pain on release f pressure confirms rebound tenderness, which is a reliable sign of peritoneal inflammation. Peritoneal inflammation accompanies appendicitis;cough tenderness that is localized to a specific spot also signal peritoneal irritation. Refer then to get CT scan

Special Procedures

-at times you may suspect that a person has ascites (free fluid from the peritoneal cavity) bc of a distended abdomen, bulging flanks, and an umbilicus that is protruding ad displaced downward -you can differentiate ascites from gaseous distention by performing the fluid wave percussion test and the shifting dullness percussion test -Abnormal findings: ascites occurs with HF, total hypertension, cirrhosis, hepatitis, pancreatitis, and cancer

Palpation with Liver

-begin palpating specific organs with the liver in the RUQ -place your left hand under the person's back parallel to the 11th and 12th ribs and left up to support the abdominal contents -place your right hand on the RUQ with fingers parallel to the midline and push deeply down and under the right costal margin and ask the person to breathe slowly -with every exhalation, move you palpating hand up 1 or 2 cm and it is normal to feel the edge of the liver, but often the liver is not palpable and you feel nothing firm -Abnormal findings: except with a depressed diaphragm , a liver palpated more than 1 to 2 cm blower the right costal margin is enlarged so record the number of cm it descends and note its consistency

Developmental: Children

-child's abdomen is proportionally larger than an adult's -protuberant appearance because of the curvature of the back -Abdominal respiration -Children's abdominal muscles are underdeveloped organs are more easily palpable

If you identify a mass

-first distinguish it from a normally palpable structure or an enlarged organ, then note: 1. Location 2. Size 3. Shape 4. Consistency 5. Surface (smooth, nodular) 6. Mobility (including movement with respiration) 7. Pulsatility 8. Tenderness

Percuss: Liver span

-first measure the height of the liver in the right MCL (mid-clavicular line) -being in the area of lung resonance and percuss down the interspaces until the sound changes to a dull quality and mark the spot (usually around 5th intercostal space) then find the abdominal tympani and percuss in the MCL and mark where the sound changes from tyranny to a dull sound (normally in the right costal margin) and then measure the distance between the 2 marks (normal liver span in adult is from 6 to 12 cm) -the height of the liver span correlates with the height of the person; taller ppl have longer livers -males have larger livers than women that are the same yet -Overall: mean liver span for men= 10.5 cm and for females = 7 cm -liver is place downward in ppl with chronic emphysema due to the hyper inflated lungs, so you will hear a dull percussion note well below the right costal margin, but the overall spend is still within normal limits -Abnormal findings: an enlarged liver span indicates liver enlargement or hepatomegaly; accurate detection of liver borders is confused by dullness above the 5th intercostal space, which occurs with lung disease (like pleural effusion or consolidation); accurate detection at the lower border is confused when dullness is pushed up with ascites or pregnancy or with gas distention in the colon, which obscures the lower border

Clinical Portrait of Intestinal Obstruction

-history of pervious abdominal surgery -vomiting -absence of stool or gas passage -distneded abdomen (after 2nd day) -x-rays shows dilated air-filled loops of small bowel with multiple air-fluid levels -hyperactive bowel sounds in early obstruction; hypoactive or silent in late obstruction -Dehydration and loss of electrolytes -Accumulation of fluid and gas in bowel proximal (above) to obstruction -colicky pain from wrong peristalsis above the obstruction -fever -pressure from excess fluid and gas may cause leaking fluid into the peritoneum -hypovolemic shock

Percuss: Costovertebral Angle Tenderness

-indirect fist percussion causes the tissue to vibrate instead of producing a sound -to assess the kidney, place one hand over the 12th rib at the costovetebral angle on the back and thump that hand with the ulnar edge of your other first and the person should feel no pain -Abnormal findings: shop pain occurs with inflammation of the kidney or paranephric area

Developmental: Infants

-newborn's bladder located above the symphysis pubis liver takes up more space in the abdomen: Liver may extend 2 cm (3/4 inch) below the rib cage -abdominal muscles weak -diastasis recti: a separation of the recuts muscles with a visible budge along the midline (more common in black infants)

Inspect the Abdomen: pulsation or movement

-noramlly you may see the pulsations from the aorta beneath the skin in the epigastric area, particularly in thin ppl with good muscle wall relaxation -resp. movement also shows in the abdomen, particularly in males -finally, waves of peristalsis sometimes are visible in very thin people -they ripple slowly and obliquely across the abdomen -Abnormal finding: marked pulsation of aorta occurs with wodenened pulse pressure (like hypertension, aortic insufficiency, thyrotoxicosis) and aortic aneurysm; marked visible peristalsis, together with a distended abdomen, indicated intersisital obstruction

Inspect the Abdomen: Umbilicus

-normally it is moline and everted with no sign of discoloration, inflammation, or hernia. It becomes everted and pushed upward with pregnancy -Abnoraml findings: everted with ascites or underlying mass; deeply sunken with obesity; enlarged, everted with umbilical hernia; bluish periumbilical color occurs with intrapertioneal bleeding (cullen sign)

Deep Palpation

-use the same technique as early but go down about 5 to 8 cm -to over come resistance of a very large or obese abdomen, use a bimanual technique and place your two hands on top of one another; the top hand does the pushing and the bottom hand is relaxed and can concentrate on the sense of palpation -mild tenderness is normally present when palpating the sigmoid colon but any other tenderness should be investigated -Abnormal findings: tenderness occurs with local inflammation, inflammation of the peritoneum or underlying organs, and with an enlarged organ whose capsules is stretched

Palpation with Spleen

-normally the spleen is not palpable and must be enlarged 3 times its size to be felt -to search for it, reach your left hand over the abdomen and begins the left side at the 11th or 12th ribs and place your right hand obliquely on the LUQ with the fingers pointing toward the left axilla and just inferior to the rib margin then push your hand deeply down and under the left costal margin and ask the pt to take a deep breath and you should feel nothing firm -when its enlarged it slides out and bumps your fingertips -it can grown so large that it extends into the lower quadrants, if you suspect this start low and you can't miss it -ABnoraml findings: the spleen enlarges with mononucleosis, trauma, leukemias and lymphomas, portal hypertension, and HIV infection; if you feel the enlarged spleen, don't continue to palpate bc it can rupture easily

Auscultate Bowel Sounds

-note the character and frequency of bowel sounds -they originate from the movement of air and fluid through the stomach and large and small intensity -depending on the time elapsed and since eating, a wide range of normal sounds can occur -they are high-pitched, giggling, cascading sounds, occurring irregularly anywhere from 5 to 30 times per minute -one type of hyperactive bowel sound that is common is hyperperistalsis which is when you fell you "stomach growling;" this is called borborygmus -a "silent abdomen" is uncommon; you must listen for 5 minutes by your watch before deciding if bowel sounds are completely absent -Abnormal findings: hyperactive sounds: loud, high-pitched, rushing, tackling sounds that signal increased motility; Hypoactive or absent sounds: follow abdominal surgery or with inflammation of the peritoneum

Special Procedures for Advanced Practice: Inspiratory Arrest (Murphy Sign)

-nromally palpating liver causes no pain, but it is a person with inflammation of the gallbladder (cholecytisis), pain occurs -hold your fingers under the liver border and ask the person to take a deep breath -a normal responded is to complete the deep breath w/o pain -Abnormal findings: when the test is positive, as the deciding liver pushes the inflamed gallbladder on the examining hand, the person feels sharp pain and abruptly stops inspiration midway

Percuss: Splenic dullness

-often the spleen is obscured by the stomach contents, but you many locate it by percussing for a dull note from the 9th to 11th intercostal space just behind the left midaxillary line -the area of dullness is usually not wider than 7 cm in the adult and should not encroach on the normal tympani over the gastric air bubble -now percuss in the lowest interspace in the left anterior axillary line and tympany should result then ask the pt to take a deep breath and normal tympany remains through full inspiration -Abnormal findings: a dull note forward of the midaxillary line indicates enlargement of the spleen and this occurs with mononucleosis, trauma, and infection; in the anterior axillary line, a change in percussion from tympany to a dull sound with full inspiration is a positive spleen percussion sign, indicating splenomegaly. this method detects mild to moderate splenomegaly before the spleen becomes palpable, as in mononucleosis, malaria, or hepatic cirrhosis

When to not use auscultation

-one assessment for which you should NOT use auscultation of the abdomen is for the correct placement of nasogastric feeding tubes -auscultation of an air bolus is not adequate to determine placement in the stomach or lung-> current evidence radiates confirming initial placement by chest x-ray and continuing assessment by measuring the external portion of the tube, testing the pH of the stomach aspirates (stomach pH is 1-3); visualizing gastric aspirates can be helpful in distinguishing gastric placement but is not helpful in determining resp. placement -ABnormal findings: the auscultation method can wrongly suggest that the feeding tube is correctly place int he stomach; serious harm or even fatality can result from administering tube-feeding material into the lung

Percuss: general tympany

-percussing allows us to assess the relative density of abdominal contents, to locate organs, and to screen for abnormal fluid or masses -first percuss lightly in all four quadrants to determine the prevailing amount of tympani and dullness -move clockwise and tyranny should predominate bc air in the intensities rises to the surface when the person is supine -Abnormal findings: dullness occurs over a distended bladder, adipose tissue, fluid, or a mass; hyperresonance is present with gaseous distention

Palpate Surface and Deep Areas

-perform palpation to judge the size, location, and consistency of certain organs and to screen for an abnormal mass or tenderness 1. Bend the pts knees 2. Keep your palpating hand low and parallel to the abdomen. Holding the hand high and pointing down would make anyone tense up 3. Teach the person to breath slow (in through nose and out through mouth) 4. Keep your own voice low and soothing 5. Try "emotive imagery" tell the pt to pretend their at the beach and let them relax 6. With a ticklish person, keep the persons hand under your own with your fingers curled over his or her fingers and move both hands around as you palpate 7. Perform palpation just after auscultation and keep the stethoscope in place and curl your fingers around it, palpating as you pretend to auscultate

Special Procedures for Advanced Practice: Iliopsoas Muscle Test

-perform when the acute abdominal pain of appendicitis is suspected -with the person supine, lift the right leg straight up, flexing at the hip then push down over the lower part of the right thigh as the person tries to hold the leg up -when the test is negative the person feels no change -for the obturator test, lift the persons right leg, flexing at the hip and 90 degrees at the knee -hold his or her ankle and rotate the leg internally and externally and there should be no pain -Abnormal finding: when the iliopsoas muscle is inflamed (which occurs with an inflamed or perforated appendix), pain is felt in RLQ; an inflamed appendix irritates the obturator muscle, and this leg movement produces pain

Epigastric hernia

-protrusion of abdominal structures presents as a small, fattly nodule at epigastrium in midline, through the linea alba -usually one can feel it rather than observe it -may be palpable only when standing

Palpation with Kidneys

-search for the right kidney by placing your hands together is a "duck-bill" position at the persons right flank and press your two hands together firmly (you need deeper palpation than with the liver and spleen) an ask the pt to take a deep breath; in most ppl you will feel no change, but occasionally you may feel the lower pole of the right kidney as a round, smooth mass that slides between your fingers and either condition is normal -left kidney is 1 cm high that right kidney and the left kidney shouldn't be palpable (no change with inhalation)

Special Procedures: Shifting dullness

-second test for ascites -in a supine person ascitic fluid settles by gravity into the flanks, displacing the air-filled bowel to the periumbilical space -you will hear a tympanic note as you percuss over the top of the abdomen bc gas-filled intestine float over the fluid and then percuss down the side of the abdomen -if fluid is present, the note wink change from tympany to dull as you reach its level and mark this spot -now turn the person on their right side (roll the pt toward you) -the fluid will gravitate to the dependent side , displacing the lighter bowel upward and begin percussing the upper side of the abdomen and move downward -the sound changed from tympany to dull sound as you reach the fluid level but this time the level of dullness is higher, upward toward the umbilicus -the shifting left of dullness indicates the presence of fluid -Abnormal findings: this test has less diagnostic valve than the fluid wave test; shifting dullness is positive with a large volume of ascites fluid; it will not detect less than 500 mL to 1100 mL of fluid (ultrasound is the best tool over both of them)

Inspect the Abdomen: Symmetry

-shine a light across the abdomen toward your or lengthwise across the person -the abdomen should be symmetric bilaterally and note any localized bulging, visible mass or asymmetric shape -small bulges can be highlighted by shadow so step the the foot of examining table and look -ask the pt to take a deep breath to further highlight any changes; it should stay smooth and symmetric or ask the pt to do a setup without using his or her hands -ABnormal findings: bulges, massess; hernia- protrusion of abdominal viscera through abnormal opening in muscle wall; sister Mary Joseph nodule is a hard nodule in the umbilicus that occurs wth metazoic cancer of stomach, large intestine ovary, or pancreas; note any localized bulging. Hernia or enlarged liver or spleen may show

Inspect the Abdomen: Contour

-stand on the person's right side and look down the abdomen an stoop or sit to gaze across the abdomen -this describes the nurtrional state and normally ranges from flat to rounded -Abnormal findings: scaphoid abdomen cavies (malnourished) and protuberant abdomen is abdominal distention (extremely rounded-> it is air that is trapped from a blockage and it makes them feel full but not heavy)

Special Procedures: Fluid Wave

-stand on the persons right side and place the ulnar edge of another examiners hand or the pts hand firmly on the abdomen in the midline and place your left hand on the persons right flank and with your right hand reach across the abdomen and give the left flank a firm strike -if ascites is present, the blow will generate a fluid wave through the abdomen, and you will feel a distinct tap on your left hand and if the abdomen is distended from gas or adipose tissue, you will feel no change -Abnormal findings: a postitive fluid wave test occurs with large amount of ascites and note any edema in the legs

Developmental: Pregnancy

-stomach rises up and impinges on the diaphragm. -Bowel sounds are diminished in the pregnant client. -Consitpiation -Hemorrhoids -Morning sickness - Heart burn (pyrosis) -Appendix is displaced -Skin changes ie. striae gravida, lines nigra

Inspect the Abdomen: hair distribution

-the pattern of pubs hair growth normally has a diamond shape is adult males and an inverted triable shape in adult female -Abnormal findings: patterns alter with endocrine or hormone abornalilites

Inspect the Abdomen: Skin

-the surface is smooth and even, with homogenous color. This is a good area to judge pigment bc it is often protected from the sun -one common pigment change is striae (lineae albicantes)- silvery white, linear, jagged marks about 1 to 6 cm long -they occur with elastic fiber's in the reticular layer of the skin are broken after rapid or prolonged stretching as in pregnancy or excessive weight gain -recent striae are pink or blue and they turn to silvery white -pigmented nevi (moles) are circumsised brown macular or papular areas -if a scar is present, draw its location in the persons record, indicating the length in cm; a surgical scar alerts you to possible presence of underlying adhesions and excess fibrous tissue -veins usually are not seen, but a find venous network may be visible in thin persons -good skin turgor reflects healthy nutrition -Abnormal findings: redness with localized inflammation; jaundice; skin glistening and taut with ascites; stare also occur with ascites; strait look purple-blue with cushing syndrome (excess adrenocoritical hormone causes the skin to be fragile and easily broken from normal stretching); unusual color or change in shape of mole; cutaneous angiomas (spider nevi) occur with portal hypertension or liver disease; lesions, rashes underlying adhesions are inflammatory bands that connect opposite sides of the serous surfaces after trauma or surgery; prominent, dilated veins occurs with portal HTN, cirrhosis, ascites, or vena naval obstruction. Veins are more visible with malnutriotn as a result of thinned adipose tissue; Poor turgor occurs with dehydration, which often accompanies GI disease

Special Procedures for Advanced Practice: The Alvarado Score

-this scoring system combines findings to assist evaluation in patients with RLQ pain and this is also called the MANTRELS score -a score of 4 or less significantly decreases the probability of the appendicitis M: migration to the right iliac fossa A: anorexia N: nausea and vomiting T: tenderness, RLQ R: rebound tenderness E: elevation of temp L: leukocyotsis (WBC sound >10,000) S: shift to the left (>75% neutrophils) -score of >_ increases probability of appendicitis

Scratch test

-this technique uses auscultation to detect the lower border of the liver -you play the stethoscope of the xiphoid (lower part of sternum) while highly stoking the skin with one finger up the MCL from the RLQ and parallel to the liver border -when you reach the liver edge, the sound is magnified in the stethoscope -they recommend this if the abdomen is distended, obese or too tender for caption of if muscles are rigid or guarded

Succussion Splash

-unrelated to peristalsis, this is a very loud smash auscultated over the upper abdomen when the infant is rocked side to side -it indicated increased air and fluid in the stomach as seen with pyloric obstruction or large hiatus hernia

Auscultate Vascular Sounds

-using firmer pressure, check over the aorta, renal arteries, iliac, and femoral arteries, esp. in ppl with hypertension; usually no such sound is present -in about 4% to 20% of healthy ppl (usually younger than 40) may have a normal bruit origination from the celiac artery -it is systolic, medium to low in pitch, and heard between the xiphoid process and the umbilicus -bruits are over arteries and venous hums are over the liver due to inflammation -Abnormal findings: note the location, pitch, and timing of a vascular sound; a systolic bruit is a pulsatile blowing sound and occurs with stenosis or occlusion of a an artery; venous hum and peritoneal friction rubs are rare

Palpation with aorta

-using your opposing thrombi and fingers palpate the aortic pulsation in the upper abdomen slightly to the left of midline -normally it is 2.5 to 4 cm wide in the adult and pulsates in an anterior direction -Abnormal findings: widened with aneurysm; prominent later pulsation with aortic aneurysm pushes the examiner's two fingers apart

Light Palpation

-with the first 4 fingers close together, depress the skin about 1 cm and make a gentle rotary motion, sliding the fingers and skin together then left the fingers (don't drag them) and move clockwise to the next location around the abdomen -save tender areas for last -voluntary guarding happens when the pt is cold, tense, or ticklish; it is bilateral and you will feel the muscles relax slightly during exhalation -if rigidity persists is is probably involuntary -Abnormal findings: involuntary rigidity is a constant borderline hardness of the muscles. It is a protective mechanism accompanying acute inflammation of the peritoneum. It may be unilateral, and the same area usually becomes painful when the person increases intra-abdominal pressure by attempting a sit-up

Physical exam techniques

1. Inspection 2. Auscultation 3. Precussion 4. Palpation -you want to auscultate before we percuss or palpate bc those will increases peristalsis which would give a false interpretation of bowel sounds; use the diaphragm end piece to auscultate bc bowel sounds a relatively high-pitched; hold the stethoscope lightly against the skin bc pushing too hard will stimulate bpwel sounds and begin in the RLQ at the ileocecal valve area bc bowl sounds and normally always present there -poisiton: supin Tools: stethoscope, pen, ruler, and tape measurer

Common Causes of Constipation found in the older adult

Decreased physical activity Inadequate intake of water Low-fiber diet -Side effects of medications -Irritable bowel syndrome -Bowel obstruction -Hypothyroidism -Inadequate toilet facilities, that is, difficulty ambulating to toilet may cause person to deliberately retain stool until it becomes hard and difficult to pass

Elderly Subjective Specific Questions

How do you acquire your groceries and prepare your meals? Do you eat alone or do you share meals with others? Please tell me all that you had to eat yesterday, starting with breakfast. Do you have any trouble swallowing these foods? What do you do right after eating, such as walking or taking a nap? How often do your bowels move? If person reports constipation: What do you mean by constipation? How much liquid is in your diet? How much bulk or fiber? Do you take anything for constipation, such as laxatives? Which ones? How often? What medications do you take?

Children Subjective Specific Questions

How often does your toddler/child eat? Does he or she eat regular meals? How do you feel about your child's eating problems? Please describe all that your child had to eat yesterday, starting with breakfast; what foods does child eat for snacks? Does toddler/child ever eat non-foods, such as grass, dirt, or paint chips? Does your child have constipation? If so, for how long? What are number of stools per day? Stools per week? How much water and juice is in child's diet? Does the constipation seem to be associated with toilet training? What have you tried to treat constipation? Does child have abdominal pain? Please describe what you have noticed and when it started. For overweight child: How long has weight been a problem? At what age did child first seem overweight? Did any change in diet pattern occur then? Describe diet pattern now. Do any others in family have similar problem? How does child feel about his or her weight?