Heath Assessment abdomen, anus and rectum

Palpation of Abdomen:

Palpate Surface and Deep Areas Perform palpation: - to judge the size, location, and consistency of certain organs - to screen for an abnormal mass or tenderness.

Percussion - Indirect

- Costovertebral Angle Tenderness - Indirect fist percussion causes the tissues to vibrate instead of producing a sound. - To assess the kidney place one hand over the 12th rib at the costovertebral angle on the back. - Thump that hand with the ulnar edge of your other fist. The person normally feels a thud but no pain. - If pain is felt it is usually indicative of kidney inflammation called + CVA tenderness.

Assessment Sequence of the Abdomen

1. Inspection 2. Auscultation 3. Percussion 4. Palpation The reason auscultation precedes percussion and palpation of the abdomen - auscultation prevents distortion of bowel sounds that might occur after percussion and palpation.

Assessment Data: Subjective Data

1. Usual bowel routine 2. Change in bowel habits 3. Rectal bleeding, blood in the stool 4. Medications (laxatives, stool softeners, iron) 5. Rectal conditions (pruritus, hemorrhoids, fissure, fistula) 6. Family history 7. Patient-centered care (diet of high-fiber foods, most recent examinations)

Stool Test

Test any stool on the glove for occult blood. - A negative response is normal. - If the stool is Hematest positive, it indicates occult blood. - There are two types of FITs: 1. liquid-based tests that store the stool sample in a hemoglobin stabilizing buffer, 2. dry-slide cards that are analyzed manually.

Inspection: Symmetry

The abdomen should be symmetrical bilaterally. Note any localized bulging, visible mass, or asymmetric shape.

Inspection: Skin

The surface is smooth and even, with homogeneous color. Rash? Scars?

Involuntary Rigidity

a constant, board-like 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.

Inspection: Hernia

a loop of bowel protruding through a weak spot in the abdominal muscles

Dyspepsia

abdominal discomfort describes as burning, bloating, gassiness (indigestion, heartburn)

Kidney Inflammation

complaining of a sharp pain along the costovertebral angles. - +CVA tenderness

Dysphagia

difficulty swallowing medications and food

Hepatomegaly

enlarged liver

Ascites

indicates the presence of fluid in the peritonium

Voluntary guarding

occurs when the person is cold, tense, or ticklish. It is bilateral, and you will feel the muscles relax slightly during exhalation. Use the relaxation measures to try to eliminate this type of guarding, or it will interfere with deep palpation.

Anal Canal

outlet of the gastrointestinal (GI) tract. - It is lined with modified skin (having no hair or sebaceous glands) that merges with rectal mucosa at the anorectal junction. - surrounded by two concentric layers of muscle, the sphincters.

Gastrointestinal bleeding

results in a black, tarry stool if high GI bleed.

Documentation:

*Normal assessment documentation:* Abdomen is soft, non-distended (ND), non-tender(NT), no masses, bruits, or pulsations, + normative BS all quads.

Deep Palpation

- *deep palpation* using the technique described earlier but push down about 5 to 8 cm (2 to 3 inches). Moving clockwise, explore the entire abdomen - Used to determine enlarged organs or masses - If you identify a mass, first distinguish it from a normally palpable structure or an enlarged organ. Then note the following: 1. Location 2. Size 3. Shape 4. Consistency (soft, firm, hard) 5. Surface (smooth, nodular) 6. Mobility (including movement with respirations) 7. Pulsatility 8. Tenderness Mild tenderness normally is present when palpating the sigmoid colon. Any other tenderness should be investigated.

Organs in the Midline:

- Aorta - Uterus (if enlarged) - Bladder (if distended)

Rebound Tenderness (Blumberg Sign)

- Assess rebound tenderness when the person reports abdominal pain or when you elicit tenderness during palpation. - Choose a site away from the painful area. Hold your hand 90 degrees, or perpendicular, to the abdomen. Push down slowly and deeply; then lift up quickly. This makes structures that are indented by palpation rebound suddenly. - A normal, or negative, response is no pain on release of pressure. Perform this test at the end of the examination because it can cause severe pain and muscle rigidity. - Charted: negative rebound tenderness

Light and Deep Palpation:

- Begin with *light palpation.* - With the first four fingers close together, depress the skin about 1 cm - Make a gentle rotary motion, sliding the fingers and skin together. Then lift the fingers (do not drag them) and move clockwise to the next location around the abdomen. - The objective here is not to search for organs but to form an overall impression of the skin surface and superficial musculature. - Save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination. - As you circle the abdomen, discriminate between voluntary muscle guarding and involuntary rigidity.

Palpation for Specific Organs - Liver

- Beginning in the RUQ - Place your left hand under the person's back parallel to the 11th and 12th ribs and lift up to support the abdominal contents. - Place your right hand on the RUQ, with fingers parallel to the midline. - Push deeply down and under the right costal margin. - Ask the person to breathe slowly. With every exhalation, move your palpating hand up 1 or 2 cm. It is normal to feel the edge of the liver bump your fingertips as the diaphragm pushes it down during inhalation. - It feels like a firm, regular ridge. - Often the liver is not palpable and you feel nothing firm.

Organs in the Right Lower Quadrant:

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

Auscultate Bowel Sounds and Vascular Sounds

- Depart from the usual examination sequence and auscultate the abdomen next. - This is done because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds. - Use the diaphragm end piece because bowel sounds are relatively high-pitched. - Hold the stethoscope lightly against the skin; pushing too hard may stimulate more bowel sounds. - Begin in the RLQ at the ileocecal valve area because bowel sounds normally are always present here

Palpate the Anus and Rectum:

- Drop lubricating jelly onto your gloved index finger. - Instruct the person that palpation is not painful but may feel like needing to move the bowels. - Ask the patient to take a deep breath and hold it. Place the pad of your index finger gently against the anal verge. You will feel the sphincter tighten and then relax. - As it relaxes ask the patient to exhale and flex the tip of your finger and slowly insert it into the anal canal in a direction toward the umbilicus. - Never approach the anus at right angles with your index finger extended. Such a jabbing motion does not promote sphincter relaxation and is painful.

Inspection Positions - Rectum, Anus, and Prostate

- Examine the male in the left lateral decubitus or standing position. - Instruct the standing male to rest his elbows on the exam table and point his toes together; this relaxes the regional muscles, making it easier to spread the buttocks. - Place the female in the lithotomy position if examining genitalia as well; use the left lateral decubitus position for the rectal area alone.

General Tympany

- First percuss lightly in all four quadrants to determine the prevailing amount of tympany and dullness. Move clockwise. - Tympany should predominate because air in the intestines rises to the surface when the person is supine.

Inspection: Contour

- Flat - Scaphoid - Rounded - Protuberant

Percussion

- General Tympany - Dullness Liver and Spleen

Prostate

- In the male the prostate gland lies in front of the anterior wall of the rectum and *2 cm* behind the symphysis pubis. - It surrounds the bladder neck and urethra - It secretes a thin, milky alkaline fluid to enhance the viability of sperm. - It is round or heart shape measuring 2.5 cm long and 4 cm in diameter.

Organs in the Right Upper Quadrant:

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

Murphy Sign

- Normally palpating the liver causes no pain. - In a person with inflammation of the gallbladder (cholecystitis), pain occurs. - Hold your fingers under the liver border. Ask the person to take a deep breath. A normal response is to complete the deep breath without pain.

Palpation for Specific Organs - Spleen

- Normally the spleen is not palpable and must be enlarged 3 times its normal size to be felt. - To search for it, reach your left hand over the abdomen and behind the left side at the 11th and 12th ribs. Lift up for support. - Place your right hand obliquely on the LUQ with the fingers pointing toward the left axilla and just inferior to the rib margin. - Push your hand deeply down and under the left costal margin and ask the person to take a deep breath. - You should feel nothing firm.

Organs in the Left Lower Quadrant:

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

Iliopsoas Muscle Test

- Perform the iliopsoas muscle test 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.

Inspection:

- Spread the buttocks wide apart with both gloved hands and observe the perianal region. - The anus normally looks moist and hairless, with coarse, folded skin that is more pigmented than the perianal skin. - The anal opening is tightly closed. - No lesions are present. - Instruct the person to hold the breath and bear down by performing a Valsalva maneuver. - No break in skin integrity or protrusion through the anal opening should be present. - Describe any abnormality in clock-face terms, with the 12 o'clock position as the anterior point toward the symphysis pubis and the 6 o'clock position toward the coccyx.

Organs in the Left Upper Quadrant:

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

Benign Prostatic Hypertrophy (BPH)

- The prostate gland commonly starts to enlarge during the middle adult years, but this is not cancer. - This *benign prostatic hypertrophy (BPH)* is present in 1 of 10 males at the age of 40 years and grows larger with age. - The diagnosis of BPH indicates that the hypertrophy is caused by hormonal imbalance that leads to the proliferation of benign adenomas (growth) - These gradually impede urine output because they obstruct the urethra.

Abdominal Areas

- the abdominal wall is divided into four quadrants by a vertical and a horizontal line bisecting the umbilicus - *epigastric* for the area between the costal margins - *umbilical* for the area around the umbilicus, - *hypogastric or suprapubic* for the area above the pubic bone.

Percuss to assess:

- the relative density of abdominal contents - to locate organs - to screen for abnormal fluid or masses.

Assessment Data: Subjective Data (9)

1. Appetite 2. Dysphagia 3. Food Intolerance 4. Abdominal pain 5. Nausea/vomiting 6. Bowel habits 7. Past abdominal history 8. Medications 9. Nutritional assessment

Review Comfort Measures:

1. Bend the person's 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 breathe slowly (in through the nose and out through the mouth). 4. Keep your own voice low and soothing. Conversation may relax the person. 5. Try "emotive imagery." For example, you might say, "Now I want you to imagine that you are dozing on the beach, with the sun warming your muscles and the sound of the waves lulling you to sleep. Let yourself relax." 6. With a very ticklish person, keep the person's hand under your own with your fingers curled over his or her fingers. Move both hands around as you palpate; people are not ticklish to themselves. 7. Alternatively perform palpation just after auscultation. Keep the stethoscope in place and curl your fingers around it, palpating as you pretend to auscultate. People do not perceive a stethoscope as a ticklish object. You can slide the stethoscope out when the person is used to being touched.

Examination of Stool

Inspect any feces remaining on the glove. Normally the color is brown, and the consistency is soft. - *Jellylike mucus shreds mixed in stool* indicate inflammation. - *Bright red blood on stool surface* indicates rectal bleeding. - *Bright red blood mixed with feces* indicates possible colonic bleeding. - *Black tarry stool with distinct malodor* indicates upper GI bleeding with blood partially digested. - *Black stool:* Also occurs with ingesting iron or bismuth preparations. - *Gray, tan stool* - Absent bile pigment (e.g., obstructive jaundice). - *Pale yellow, greasy stool*: Increased *fat content (steatorrhea)*, as occurs with malabsorption syndrome. - *Occult bleeding* may indicate cancer of the colon, further testing is needed.

Inspection: Umbilicus

Normally it is midline and inverted, with no sign of discoloration, inflammation, or hernia - *Hernia* is a loop of bowel protruding through a weak spot in the abdominal muscles.

Inspection: Pulsation or Movement

Pulsations, Respiratory, waves of peristalsis.

Rectum

the distal portion of the large intestine, it extends from the sigmoid colon.

The external sphincter surrounds

the internal sphincter it is under voluntary control.

Except for the passing of feces and gas,

the sphincters keep the anal canal tightly closed.

Umbilical hernia

umbilicus is enlarged and everted.

The internal sphincter is

under involuntary control by the autonomic nervous system.

Auscultation - Vascular Sounds

• As you listen to the abdomen, note the presence of any vascular sounds or bruits. • Using firmer pressure, check over the aorta, renal arteries, iliac, and femoral arteries, especially in people with hypertension. • Usually no sound is present.

NG Placement

• For safe practice, one assessment for which you should NOT use auscultation of the abdomen is for the correct placement of nasogastric feeding tubes. • Despite evidence showing that auscultation of an air bolus is not adequate to determine placement in stomach or lung, you may see some nurses still practicing this method. • Current evidence mandates confirming initial placement by chest x-ray and continuing assessment by testing the pH of stomach aspirates (stomach pH is 1.0 to 3.0, whereas intestinal pH is 6.0 to 9.0).29 • Visualizing gastric aspirates can be helpful in distinguishing gastric (grassy green or colorless) versus intestinal (yellow, bile stained, clear or cloudy) placement but is not helpful in determining respiratory placement

Auscultation - 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 intestine. • Bowel sounds are high-pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5 to 30 times per minute. • Do not bother to count bowel sounds. Judge if they are present or are hypoactive or hyperactive. • One type of hyperactive bowel sounds is fairly common: hyper peristalsis, when you feel your "stomach growling," termed borborygmus. • A perfectly "silent abdomen" is uncommon; you must listen for 5 minutes by your watch before deciding if bowel sounds are completely absent.