EXAM 1 ABDOMEN

Abdominal history

Any history of gastrointestinal problems, such as ulcer, gallbladder disease, hepatitis/jaundice, appendicitis, colitis, or hernia? Ever had any operations in abdomen? Please describe. Any problems after surgery? Any abdominal x-ray studies? What were results?

Nausea and Vomiting Questions

Any nausea or vomiting? How often? How much comes up? What is the color? Is there an odor? Is it bloody? Is nausea and vomiting associated with colicky pain, diarrhea, fever, or chills? What foods did you eat in last 24 hours? Where did you eat? At home, school, restaurant? Is there anyone else in the family with the same symptoms in the last 24 hours?

Dysphagia

Any difficulty swallowing? When did you first notice this?

Inspection of the Abdomen IV

Pulsation or movement Normally you may see pulsations from aorta beneath skin in epigastric area, particularly in thin persons with good muscle wall relaxation Hair distribution Pattern of pubic hair growth normally has diamond shape in adult males and an inverted triangle shape in adult females Demeanor Comfortable person is relaxed quietly on examining table and has a benign facial expression and slow, even respirations

Abdominal Pain Questions I

Any abdominal pain? Please point to it. Is pain in one spot or does it move around? How did it start? How long have you had it? Is it constant, or does it come and go? Does it occur before or after meals? Does it peak? When? How would you describe the character of the pain: cramping (colic type), burning in pit of stomach, dull, stabbing, or aching? Is pain relieved by food, or worse after eating?

Appetite

Any change in appetite? Is this a loss of appetite? Any change in weight? How much weight gained or lost? Over what time period? Is the weight loss due to diet?

Ascites

abnormal accumulation of fluid in the abdomen

Abnormal Findings: Abnormal Bowel Sounds

Hypoactive bowel sounds Hyperactive bowel sounds Succussion splash

Blumberg's sign AKA Rebound Tenderness

Pain felt on abrupt release of steady pressure (rebound tenderness) over the site of abdominal pain.

Physical Assessment/ Objective Data

Inspection of the Abdomen Contour Symmetry Umbilicus Skin Pulsation or movement Hair distribution Demeanor

Auscultation of Bowel Sounds

(a) Auscultation of Bowel Sounds This is done because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds. Use diaphragm because bowel sounds are relatively high pitched. Hold stethoscope lightly against skin; pushing too hard may stimulate more bowel sounds. Bowel sounds originate from movement of air and fluid through 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 them Begin in RLQ at ileocecal valve area because bowel sounds are normally always present here. Note character and frequency of bowel sounds Judge if they are normal, hypoactive, or hyperactive Perfectly "silent abdomen" is uncommon; you must listen for 5 minutes by your watch before deciding bowel sounds are completely absent Borborygmus is the sound of hyper peristalsis

MANTRELS score

-to diagnose appendicitis

Developmental Competence: Aging Adult

Aging alters appearance of abdominal wall Changes of the GI system occur with aging, but most do not significantly affect function as long as no disease is present Salivation decreases, leading to a dry mouth and decreased sense of taste Esophageal emptying and gastric acid secretion are delayed Incidence of gallstones increases with age Although liver size decreases, most liver functions remain normal; however, drug metabolism is impaired Aging adults frequently report constipation

Liver Span Assessment II

Also, males have larger liver span than females of the same height Overall, mean liver span is 10.5 cm for males and 7 cm for females One variation occurs in people with chronic emphysema, in which liver displaced downward by hyperinflated lungs Although you hear a dull percussion note well below right costal margin, overall span is still within normal limits Clinical estimation of liver span important to screen for hepatomegaly and to monitor changes in liver size However, this measurement is a gross estimate; liver span may be underestimated because of inaccurate detection of upper border

Hooking Technique

An alternative method of palpating liver is to stand up at person's shoulder and swivel your body to right so that you face person's feet.Hook your fingers over costal margin from above. Ask person to take a deep breath. Try to feel liver edge bump your fingertips.

Health History/ Subjective Data

Appetite Dysphagia Food intolerance Abdominal pain Nausea and vomiting Bowel habits Past abdominal history Medications Nutritional assessment

Food intolerance

Are there any foods you cannot eat? What happens if you do eat them: allergic reaction, heartburn, belching, bloating, or indigestion? Do you use antacids? How often?

Special Procedures

At times, you may suspect that a person has ascites (free fluid in the peritoneal cavity) because of distended abdomen, bulging flanks, and an umbilicus that is protruding and displaced downward You can differentiate ascites from gaseous distention by performing two percussion tests Fluid wave test Shifting dullness test

Developmental Competence: Infant II

Auscultation Auscultation yields only bowel sounds, metallic tinkling of peristalsis No vascular sounds should be heard Percussion Percussion finds tympany over stomach (the infant swallows some air with feeding) and dullness over liver Percussing the spleen is not done Abdomen sounds tympanitic, although it is normal to percuss dullness over bladder; dullness may extend up to umbilicus Palpation Aid palpation by flexing baby's knees with one hand while palpating with other

Light Palpation

Begin with light palpation With first four fingers close together, depress skin about 1 cm Make gentle rotary motion, sliding fingers and skin together Then lift fingers (do not drag them) and move clockwise to next location around abdomen Objective is not to search for organs but to form an overall impression of skin surface and superficial musculature Save examination of any identified tender areas until last This method avoids pain and resulting muscle rigidity that would obscure deep palpation later in examination As you circle abdomen, discriminate between voluntary muscle guarding and involuntary rigidity Voluntary guarding occurs when person is cold, tense, or ticklish; it is bilateral, and you will feel muscles relax slightly during exhalation; use relaxation measures to try to eliminate this type of guarding If rigidity persists, it is probably involuntary

Developmental Competence: Child II

Easily palpable, on the left, the spleen also is easily palpable with a soft, sharp, movable edge Usually you can feel 1 to 2 cm of right kidney and tip of left kidney Percussion of liver span measures about 3.5 cm at age 2 years, 5 cm at age 6 years, and 6 to 7 cm during adolescence In assessing abdominal tenderness, remember that young child often answers this question affirmatively no matter how abdomen actually feels Use objective signs to aid assessment, such as a cry changing in pitch as you palpate, facial grimacing, moving away from you, and guarding School-age child has a slim abdominal shape as he or she loses potbelly This slimming trend continues into adolescence Adolescent easily embarrassed with exposure of abdomen, and adequate draping is necessary Physical findings are same as those listed for adult

Abnormal Findings: On Palpation of Enlarged Organs

Enlarged liver Enlarged nodular liver Enlarged gallbladder Enlarged spleen Enlarged kidney Aortic aneurysms

Educational Opportunities

Explain to parents of children with birth defects such as cleft lip and palate about dietary adjustments and safe feeding practices. Dietary changes including small, frequent meals of dry foods can relieve nausea and vomiting during pregnancy. High-fiber diet and increased fluid intake can relieve constipation associated with pregnancy and older adults. Regular exercise will also enhance abdominal function. Regular dental hygiene from childhood to older adulthood will reduce problems with missing teeth, periodontal disease, and ill-fitting dentures. Safe food handling and preparation can reduce the risk of foodborne illnesses, such as hepatitis A or food poisoning. Immunizations for hepatitis A and B are readily available. In infants and children, immunizations are required in preparation for attendance at public schools. Medications, such as NSAIDs and narcotics for pain, can cause or exacerbate problems with the GI system. Teaching about alcohol abuse can be important at an early age and throughout the life span. Dietary practices should be explored to determine cultural and lifestyle influences on the gastrointestinal function.

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

Bowel habits

How often do you have a bowel movement? What is the color and consistency? Any diarrhea or constipation? How long? Any recent change in bowel habits? Use laxatives? Which ones? How often do you use them?

Developmental Competence: Infants and Children

In newborn, umbilical cord shows prominently on abdomen Contains two arteries and one vein Liver takes up proportionately more space in abdomen at birth than in later life In healthy term neonates, lower edge may be palpated 0.5 to 2.5 cm below right costal margin Urinary bladder located higher in abdomen than in adult Lies between symphysis and umbilicus During early childhood, abdominal wall is less muscular, so organs may be easier to palpate

Costovertebral Angle Tenderness

Indirect fist percussion causes tissues to vibrate instead of producing a sound To assess kidney, place one hand over 12th rib at costovertebral angle on back Thump that hand with ulnar edge of your other fist Person normally feels thud but no pain Its usual sequence in complete examination is with thoracic assessment, when person is sitting up and you are standing behind

Developmental Competence: Infant I

Inspection Contour of abdomen is protuberant because of immature abdominal musculature Skin contains a fine, superficial venous pattern; this may be visible in lightly pigmented children up to puberty At birth, it is white and contains two umbilical arteries and one vein surrounded by mucoid connective tissue, called Wharton jelly Umbilical stump dries within a week, hardens, and falls off by 10 to 14 days; skin covers area by 3 to 4 weeks Abdomen should be symmetric, although two bulges common May note an umbilical hernia; appears at 2 to 3 weeks and especially prominent when infant cries Reaches maximum size at 1 month (up to 2.5 cm or 1 in.) and usually disappears by 1 year Another common variation is diastasis recti, a separation of rectus muscles with a visible bulge along midline (Condition more common with black infants, and it usually disappears by early childhood) Abdomen shows respiratory movement Only other abdominal movement you should note is occasional peristalsis, which may be visible because of thin musculature

Summary Checklist: Abdomen Examination

Inspection Contour, symmetry, umbilicus, skin, pulsation or movement, hair distribution, and demeanor Auscultation Bowel sounds; note any vascular sounds Percussion All four quadrants and borders of liver and spleen Palpation Light and deep palpation in all four quadrants, and palpate for liver and spleen

Murphy's sign

Inspiratory arrest (Murphy's sign) Pain with palplation of gall bladder (seen with cholecystitis) Technique: Have the patient lie supine on the exam table Place your fingers under the liver border Ask the patient to take a deep breath. Note: You should feel the rib cage move toward you during inspiration Results: Positive: The patient experiences pain/tenderness sufficient to cause an abrupt halt in inspiration: acute cholecystitis is suspected. Negative: The patient is able to complete a full inspiration without significant pain/tenderness

Abdominal Pain Questions II

Is pain associated with menstrual period or irregularities, stress, dietary indiscretion, fatigue, nausea and vomiting, gas, fever, rectal bleeding, frequent urination, or vaginal or penile discharge? What makes the pain worse: food, position, stress, medication, or activity? What have you tried to relieve pain: resting, using a heating pad, changing position, or taking medication?

McBurney's Point

It is the point within the right lower quadrant: one-third the distance from the anterior iliac spine to the umbilicus on a line connecting the two. Tenderness at McBurney's point is suspicious for appendicitis

Contour

Stand on person's right side and look down on abdomen Then stoop or sit to gaze across abdomen Your head should be slightly higher than abdomen Determine profile from rib margin to pubic bone; contour describes nutritional state and normally ranges from flat to rounded

Culture and Genetics I

Lactase is digestive enzyme necessary for absorption of carbohydrate lactose (milk sugar) In some racial groups, lactase activity is high at birth but declines to low levels by adulthood These people are lactose intolerant and have abdominal pain, bloating, and flatulence when milk products are consumed Estimated incidence of lactose intolerance is 15% of Whites, 50% of Mexican Americans, and 80% of Blacks

Palpation of Left Kidney

Left kidney sits 1 cm higher than right kidney and is not palpable normally Search for it by reaching your left hand across abdomen and behind left flank for support Push your right hand deep into abdomen, and ask person to breathe deeply You should feel no change with inhalation

Light and Deep Palpation

Mild tenderness normally present when palpating sigmoid colon Any other tenderness should be investigated If you identify a mass, then note the following: Location Size Shape Consistency: soft, firm, hard Surface: smooth, nodular Mobility, including movement with respirations Pulsatility Tenderness

Developmental Competence: Pregnant Woman

Nausea and vomiting, or "morning sickness," is an early sign of pregnancy for most pregnant women, starting between first and second missed periods Cause unknown; may be due to hormone changes, such as production of human chorionic gonadotropin (hCG) Another symptom is "acid indigestion" or heartburn (pyrosis) caused by esophageal reflux Gastrointestinal motility decreases, which prolongs gastric emptying time Decreased motility causes more water to be reabsorbed from colon, which leads to constipation Constipation and increased venous pressure in lower pelvis may lead to hemorrhoids Enlarging uterus displaces intestines upward and posteriorly Bowel sounds are diminished Appendix displaced upward and to the right Skin changes on abdomen include striae and linea nigra

Palpation of Spleen

Normally spleen is not palpable and must be enlarged three times its normal size to be felt To search for it, reach your left hand over abdomen and behind left side at the 11th and 12th ribs Lift up for support; place your right hand obliquely on LUQ with fingers pointing toward left axilla and just inferior to rib margin Push your hand deeply down and under left costal margin, and ask person to take deep breath You should feel nothing firm When enlarged, spleen slides out and bumps your fingertips When this condition is suspected, start low so you will not miss it An alternative position is to roll person onto his or her right side to displace spleen more forward and downward

Auscultation of Vascular Sounds

Note presence of any vascular sounds or bruits. Using firmer pressure, check over aorta, renal arteries, iliac, and femoral arteries, especially in people with hypertension. Usually no such sound is present.

Nutritional assessment

Now I would like to ask you about your diet Please tell me all food you ate yesterday, starting with breakfast Which fresh markets are located in your neighborhood?

Deep Palpation

Now perform deep palpation using same technique described earlier, but push down about 5 to 8 cm (2 to 3 inches) Moving clockwise, explore entire abdomen To overcome resistance of a very large or obese abdomen, use a bimanual technique Place your two hands on top of each other Top hand does pushing; bottom hand relaxed and can concentrate on sense of palpation

Developmental Competence: Aging Adult

On inspection, you may note increased deposits of subcutaneous fat on abdomen and hips because it is redistributed away from extremities Abdominal musculature is thinner and has less tone than that of younger adult, so in absence of obesity you may note peristalsis Because of thinner, softer abdominal wall, organs may be easier to palpate, in the absence of obesity Liver is easier to palpate; normally you will feel liver edge at or just below costal margin With distended lungs and depressed diaphragm, liver can be palpated lower, descending 1 to 2 cm below costal margin with inhalation Kidneys are easier to palpate

Abnormal Findings: Abdominal Distention

Obesity Air or gas Ascites Ovarian cyst Pregnancy Feces Tumor

Culture and Genetics II

Obesity is caused by a complex interaction of genetics, dietary consumption, physical activity leading to an obesogenic environment Globally and within the U.S., the incidence of obesity has increased significantly NHANES data show significant differences in obesity among racial groups Obesity presentation across the life cycle leads to development of significant comorbidities Recommendations: healthy food patterns, decreased consumption of sweetened/processed foods, and increased physical activity

Splenic Dullness

Often spleen obscured by stomach contents, but you may locate it by percussing for a dull note from 9th to 11th intercostal space just behind left midaxillary line Area of splenic dullness normally is not wider than 7 cm in adult and should not encroach on normal tympany over gastric air bubble Percuss in lowest interspace in left anterior axillary line Tympany should result; ask person to take a deep breath; normally tympany remains through full inspiration

Percussion and Tympany

Percuss general tympany, liver, and splenic dullness Percuss to assess relative density of abdominal contents, to locate organs, and to screen for abnormal fluid or masses General tympany First, percuss lightly in all four quadrants to determine prevailing amount of tympany and dullness Move clockwise; tympany should predominate because air in intestines rises to surface when person is supine

Liver Span Assessment I

Percuss to map out boundaries of certain organs Measure height of liver in right midclavicular line For consistent placement of midclavicular line landmark, remember to palpate acromioclavicular and sternoclavicular joints, and judge line at point midway between two marks Begin in area of lung resonance, and percuss down interspaces until sound changes to a dull quality Mark spot, usually in fifth intercostal space Find abdominal tympany, and percuss up in midclavicular line Mark where sound changes from tympany to a dull sound, normally at right costal margin Measure distance between two marks; normal liver span in adult ranges from 6 to 12 cm Height of liver span correlates with height of person; taller people have longer livers

Developmental Competence: Infant III

Percussion Percussion finds tympany over stomach (the infant swallows some air with feeding) and dullness over liver Percussing the spleen is not done Abdomen sounds tympanitic, although it is normal to percuss dullness over bladder; dullness may extend up to umbilicus Palpation Aid palpation by flexing baby's knees with one hand while palpating with other Alternatively, you may hold upper back and flex neck slightly with one hand; offer pacifier to a crying infant Liver fills RUQ; normal to feel liver edge at right costal margin or 1 to 2 cm below Normally you may palpate spleen tip and both kidneys and bladder Also easily palpated are cecum in RLQ, and sigmoid colon, which feels like a sausage in left inguinal area Make note of newborn's first stool, a sticky, greenish-black meconium stool within 24 hours of birth

Palpate Surface and Deep Areas

Perform palpation Judge size, location, and consistency of certain organs and screen for an abnormal mass or tenderness With either technique, note location, size, consistency, and mobility of any palpable organs and presence of any abnormal enlargement, tenderness, or masses Making sense of what you are feeling is more difficult than it looks Inexperienced examiners complain that abdomen "all feels same," as if they are pushing their hand into a soft sofa cushion Helps to memorize anatomy and visualize what is under each quadrant as you palpate

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. (Note: Evidence shows that the Obturator Test, another technique that stretches the obturator muscle, does not work to diagnose appendicitis. When the iliopsoas muscle is inflamed (which occurs with an inflamed or perforated appendix), pain is felt in the RLQ right lower quadrant.

Abnormal Findings: Friction Rubs and Vascular Sounds

Peritoneal friction rub Arterial bruit Venous hum

Palpation of Liver

Place your left hand under person's back parallel to 11th and 12th ribs and lift up to support abdominal contents Place your right hand on RUQ, with fingers parallel to midline Push deeply down and under right costal margin Ask person to take a deep breath; it is normal to feel edge of liver bump your fingertips as diaphragm pushes it down during inhalation It feels like a firm regular ridge Often liver is not palpable

Palpation of Right Kidney

Search for right kidney by placing your hands together in a "duck-bill" position at person's right flank Press your two hands together firmly (you need deeper palpation than that used with the liver or spleen), and ask person to take deep breath In most people, you will feel no change Occasionally, you may feel lower pole of right kidney as a round, smooth mass slide between your fingers Either condition is normal

Inspection of the Abdomen III

Skin One common pigment change is striae, silvery white, linear, jagged marks about 1 to 6 cm long Occur when elastic fibers in reticular layer of skin are broken after rapid or prolonged stretching, as in pregnancy or excessive weight gain; recent striae are pink or blue, then they turn silvery white Pigmented nevi (moles), circumscribed brown macular or papular areas, common on abdomen Normally no lesions are present, although you may note well-healed surgical scars If a scar is present, draw its location in person's record, indicating length in centimeters. Occasionally, a person forgets about an operation while providing the history; if you note a scar now, ask about it. Surgical scar alerts you to possible presence of underlying adhesions and excess fibrous tissue.

Inspection of the Abdomen II

Symmetry Shine a light across abdomen toward you, or shine it lengthwise across the person Abdomen should be symmetric bilaterally Umbilicus Normally it is midline and inverted, with no sign of discoloration, inflammation, or hernia Becomes everted and pushed upward with pregnancy Umbilicus is common site for piercings in young women; site should not be red or crusted Skin Surface smooth and even, with homogeneous color; good area to judge pigment because often protected from sun Fine venous network may be visible in thin persons Good skin turgor reflects healthy nutrition; gently pinch up a fold of skin; then release to note skin's immediate return to original position

The nurse is assessing a patient's abdomen and notices a thrill in the right upper quadrant. The nurse should suspect which of the following? This is a normal finding and should be documented as such. Possible abdominal aortic aneurysm Possible appendicitis Possible gallstones

The correct answer is 2. This may be an abdominal aortic aneurysm and requires emergency intervention and attention. Answer 1 is incorrect because thrills and bruits are not considered to be normal findings. Answer 3 is incorrect because appendicitis would present with rebound tenderness in the right lower quadrant; no thrill would be present. Answer 4 is incorrect because gallstones present with pain and no thrill.

The nurse suspects appendicitis. How should the nurse proceed with the assessment of the patient's abdomen? The nurse should ask the patient to point to where the pain is located and palpate that region first. The nurse should not palpate the patient's abdomen because this will illicit pain. The nurse should listen for a bruit at McBurney's point. The nurse should palpate last and note rebound tenderness at McBurney's point.

The correct answer is 4. Rebound tenderness in the right lower quadrant at McBurney's point is a common finding for appendicitis. Palpation should be done last. Answer 1 is incorrect because palpation should be done last so as not to illicit pain and abdominal rigidity. Answer 2 is incorrect because palpation is a necessary assessment. Answer 3 is incorrect because a bruit in the abdominal region would be indicative of an abdominal aortic aneurysm.

The Alvarado score

This scoring system combines findings to assist evaluation in patients with RLQ pain. Also called the MANTRELS score, from the mnemonic in the following list, a score of 4 or less significantly decreases the probability of appendicitis

Abnormal Findings: Abnormalities on Inspection

Umbilical hernia: a bulging of omentum or intestine through a weakness or incomplete closure in the umbilical ring. It is accentuated by increase abdominal pressure (crying, coughing, vomiting or straining. Epigastric hernia: Bulging of abdominal structures at epigastrium in midline, through the linea alba. Usually it is felt rather than observed. Incisional hernia: a bulge near an old operative scar that does show when the patient is supine but it shows when the person increases intra-abdominal pressure by a sit-up, standing or Valsalva maneuver. Diastasis recti: separation of the abdominal rectus muscles. A ridge is revealed when intrabdominal pressure is increase by raising head when supine

Developmental Competence: Child I

Under age 4 years, abdomen looks protuberant when child is both supine and standing After age 4 years, potbelly remains when standing because of lumbar lordosis, but abdomen looks flat when supine Normal movement on abdomen includes respirations, which remain abdominal until 7 years To palpate abdomen, position young child on parent's lap as you sit knee-to-knee with parent Flex knees up, and elevate head slightly Child can "pant like a dog" to further relax abdominal muscles Hold your entire palm flat on abdominal surface for a moment before starting palpation This accustoms child to being touched If the child is very ticklish, hold his or her hand under your own as you palpate; or apply stethoscope and palpate around it Liver: Remains easily palpable 1 to 2 cm below right costal margin; edge is soft and sharp and moves easily

Developmental Competence: Child III

Use objective signs to aid assessment, such as a cry changing in pitch as you palpate, facial grimacing, moving away from you, and guarding School-age child has a slim abdominal shape as he or she loses potbelly This slimming trend continues into adolescence Adolescent easily embarrassed with exposure of abdomen, and adequate draping is necessary Physical findings are same as those listed for adult

Palpation of the Aorta

Using your opposing thumb and fingers, palpate aortic pulsation in upper abdomen slightly to left of midline Normally it is 2.5 to 4 cm wide in adult and pulsates in an anterior direction

Medications

What medications are you currently taking? How much alcohol do you drink each day? Each week? When was your last alcoholic drink? Do you smoke? How many packs per day? For how long?

Light and Deep Palpation I

With either technique, note location, size, consistency, and mobility of any palpable organs and presence of any abnormal enlargement, tenderness, or masses Making sense of what you are feeling is more difficult than it looks Inexperienced examiners complain that abdomen "all feels same," as if they are pushing their hand into a soft sofa cushion Helps to memorize anatomy and visualize what is under each quadrant as you palpateAlso remember that some structures are normally palpable Mild tenderness normally present when palpating sigmoid colon Any other tenderness should be investigated If you identify a mass, first distinguish it from a normally palpable structure or an enlarged organ

Obturator test

internal rotation of the right leg with the leg flexed at 90* at the hip and knee and a resultant tightening of the internal obturator muscle which may cause abdominal discomfort Could be a sign to appendicitis or peritoneal inflammation