Physical Assessment: CH 22 Abdomen

Shifting dullness is a test for:

ascites

Paralytic ileus

complete absence of peristaltic movement that may follow abdominal surgery or complete bowel obstruction

pyloric stenosis

congenital narrowing of pyloric sphincter, forming outflow obstruction of stomach

Cholecystitis

inflammation of the gallbladder

Peritonitis

inflammation of the peritoneum

Viscera

internal organs

Peritoneum

double envelope of serous membrane that lines the abdominal wall and covers the surface of most abdominal organs

Diastasis recti

midline longitudinal ridge in the abdomen, a separation of abdominal rectus muscles

linea alba

midline tendinous seam joining the abdominal muscles

Cecum

first or proximal part of large intestine

Pyrosis

heartburn; burning sensation in upper abdomen due to reflux of gastric acid

Tymphany

high-pitched, musical, drumlike percussion note heard when percussing over the stomach and intestine

Peritoneal friction rub

rough grating sound heard through the stethoscope over the site of peritoneal inflammation

Hyperactive bowel sounds are

all of the above high pitched, rushing, tinkling

straie

(lineae albicantes) silvery white or pink scar tissue formed by stretching of abdominal skin as with pregnancy or obesity

Name the organs that are normally palpable in the abdomen

-xiphoid process -normal liver edge -right kidney(lower pole) -Pulsatile aorta -Rectus muscles (lateral borders) -Sacral promontory -Ascending colon -Cecum -sigmoid colon -Uterus (gravid) -full bladder

The absence of bowel sounds is established after listening for:

5 full minutes

Distinguish abdominal wall masses from intra-abdominal masses

An abdominal wall mass is attached to the abdominal wall; an intra-abdominal mass is located within the abdominal cavity or attached to an organ.

Auscultation of the abdomen may reveal bruits of the _______________arteries

Aortic, renal, iliac, and femoral

Auscultating the abdomen is begun in the right lower quadrant (RLQ) because

Bowel sounds are always normally present here

Differentiate the following abdominal sounds: normal, hyperactive, and hypoactive bowel sounds; succession splash; bruit

Characteristics of bowel sounds: • Normal bowel sounds—high-pitched, gurgling, cascading sounds that occur irregularly from 5 to 30 times per minute. • Hyperactive bowel sounds—loud, high-pitched, rushing, tinkling sounds that signal increased motility. • Hypoactive bowel sounds—diminished or absent sounds that signal decreased motility. • Succession splash—a very loud splash, not r/t peristalsis, that is auscultated over the upper abdomen when the infant is rocked side to side; it indicates increased air and fluid in the stomach. • Bruit—a systolic bruit is a pulsatile, blowing sound that indicates turbulent blood flow, as found in constricted, abnormally dilated, or tortuous vessels.

Describe the procedure for auscultation of the bowel sounds

Hold the diaphragm endpiece of the stethoscope lightly against the skin and listen to the bowel sounds (see Fig. 22.6).

Discuss inspection of the abdomen, including findings that you should note.

Inspection of the abdomen: • Contour—the contour describes the nutritional state and normally ranges from flat to rounded. See Fig. 22.7. • Symmetry—the abdomen should stay smooth and symmetric. • Umbilicus—normally it is midline and inverted. • Skin—the surface is smooth and even, with homogenous color. • Pulsation or movement—pulsations in the epigastric area may be visible in thin persons with good muscle wall relaxation. Abdominal respiratory movements may be evident, especially in males. Peristalsis may be visible in thin persons. • Hair distribution—the pattern of pubic hair growth normally has a diamond shape in adult males and an inverted triangle shape in adult females. • Demeanor—a comfortable person is relaxed during the examination. For a description of inspection techniques, see text under "Inspect the Abdomen."

Select the sequence of techniques used during an examination of the abdomen

Inspection, auscultation, percussion, palpation

Contracts rigidity with voluntary guarding

Involuntary rigidity is a constant boardlike hardness of the muscles; it is a protective measure that accompanies inflammation of the peritoneum, and it can be unilateral. • Voluntary guarding occurs when the person is cold, tense, or ticklish; it is bilateral, and you will feel the muscles relax slightly during exhalation.

Right upper quadrant tenderness may indicate pathology in the:

Liver, pancreas, or ascending colon

A positive Murphy sign is best described as:

Pain felt when taking a deep breath when the examiners fingers are not he approximate location of the inflamed gallbladder

Differentiate between light and deep palpation, and explain the purpose of each.

Palpation techniques include: • Light palpation—depressing the skin about 1 cm and using a gentle rotary motion, move over the surface of the abdomen. See Fig. 22.15. • Deep palpation—depressing the skin about 5 to 8 cm (2 to 3 inches), move clockwise over the entire abdomen. See Fig. 22.16. • Light palpation may reveal muscle guarding, rigidity, large masses, or tenderness. • Deep palpation reveals the location, size, consistency, and mobility of any palpable organ and the presence of any abnormal enlargement, tenderness, or masses.

Describe the proper positioning and preparation of the patient for the abdominal examination

Positioning and preparation include: • Ensure proper lighting in the examination room. Expose the abdomen so that it is fully visible, but drape the genitalia and female breasts. • Make sure the patient has emptied his or her bladder. • Keep the room warm to avoid tensing of muscles and chilling. • Position the patient supine with the head on a pillow, the knees bent or on a pillow, and the arms at the side or across the chest. Do not allow the arms to be raised over the head because this may tense the abdominal muscles. • Ensure that the stethoscope endpiece is warm, your hands are warm, and your fingernails are short. Cold hands and a cold stethoscope cause muscle tensing. • Inquire about painful areas and examine such areas last to avoid muscular guarding. • Use distraction techniques to help the patient relax while you perform palpation.

Describe rebound tenderness

Rebound tenderness, also known as Blumberg sign, should be assessed when a person reports abdominal pain or when you elicit tenderness during palpation. Choose a site away from the painful area and 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. This procedure should be performed at the end of the examination because it can cause severe pain or muscle rigidity. The presence of rebound tenderness is a reliable sign of peritoneal inflammation, which accompanies appendicitis. See Fig. 22.27.

Tenderness during abdominal palpation is expected when palpating the:

Sigmoid colon

A woman has striae on the abdomen. Which color indicates long-standing striae?

Silvery white

Costovertebral angle (CVA)

angle formed by the 12th rib and the vertebral column on the posterior thorax, overlying the kidney

State the rationale for performing auscultation of the abdomen before palpation or percussion

The abdomen is auscultated after inspection because percussion and palpation can increase peristalsis, which may result in a false interpretation of bowel sounds.

Describe the procedure and rational for determining costovertebral angle(CVA) tenderness

To assess for costovertebral angle tenderness, 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. The presence of sharp pain indicates inflammation of the kidney or paranephric area. See Fig. 22.14.

List 4 conditions that may alter normal percussion notes heard over the abdomen

Tympany is the predominant percussion sound across the abdomen, because air in the intestines rises to the surface when the person is supine. Dullness occurs over dense organs such as the liver and spleen, a distended bladder, adipose tissue, fluid, or a mass. With ascites, tympany occurs at the top where the intestines float, and dullness occurs over the fluid. With feces, tympany predominates but there is scattered dullness over the fecal mass. Gas causes tympany over a large area of the abdomen.

Which of the following can be noted through inspection of a patient's abdomen?

Venous pattern, peristaltic waves, and abdominal contour

Ascites

abnormal accumulation of serous fluid within the peritoneal cavity, associated with heart failure, cirrhosis, cancer, or portal hypertension

Hepatomegaly

abnormal enlargement of the liver

splenomegaly

abnormal enlargement of the spleen

Hernia

abnormal protrusion of bowel through weakening in abdominal musculature

Scaphoid

abnormally sunken abdominal wall, as with malnutrition or underweight

Bruit

blowing, swooshing sound heard through a stethoscope when an artery is partially occluded

Aneurysm

defect or sac formed by dilation in artery wall due to atherosclerosis, trauma, or congenital defect

Umbilicus

depression on the abdomen marking site of entry of umbilical cord

Dysphagia

difficulty swallowing

Inguinal ligament

ligament extending from pubic bone to anterior superior iliac spine, forming lower border of abdomen

Anorexia

loss of appetite for food

Borborygmi

loud, gurgling bowel sounds signaling increased motility or hyperperistalsis; occurs with early bowel obstruction, gastroenteritis, diarrhea

Costal margin

lower border of rib margin formed by the medial edges of the 8th, 9th, and 10th ribs

Rectus abdominis muscles

midline abdominal muscles extending from rib cage to pubic bone

Epigastrium

name of abdominal region between the costal margins

suprapubic

name of abdominal region just superior to pubic bone

A positive Blumberg sign indicates

peritoneal inflammation

The left upper quadrant (LUQ) contains the:

spleen

Contrast visceral pain with somatic(parietal) pain

• Visceral pain comes from an internal organ and is dull, general, and poorly localized. • Somatic (parietal) pain is due to inflammation of overlying peritoneum and is sharp, precisely localized, and aggravated by movement.