Jarvis Health Assessment Chapter 22 Abdomen

Appetite: Ask about

changes in appetite—time period and amount changes in weight—loss or gain (amount) and time period

Perfectly "silent abdomen" is uncommon; you must listen for 5 minutes by your watch before deciding bowel sounds are

completely absent

Aging adults frequently report

constipation ROME III standardizes symptoms criteria for functional constipation

Abdominal distention: air or gas

inspection: single round curve auscultation: depends on cause of gas (e.g. decreased or absent bowel sounds with ileus); hyperactive with early intestinal obstruction percussion: tympany over large area palpation: may have muscle spasm of abdominal wall

viscera

internal organs

Changes of the GI system occur with aging, but most do not significantly affect function as long as no

disease is present

mesentaries

double layers of the parietal peritoneum, extend from the abdominal wall as pathways for blood vessels, nerves, and lymphatics. Also serves as supporting networks to suspend and stabilize the 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

Abdominal profiles

flat, rounded, scaphoid, protuberant

rectus abdominis

flexes vertebral column and compresses abdominal wall

Using firmer pressure, check over aorta, renal arteries, iliac, and femoral arteries, especially in people with

hypertension

In the aging adult, although liver size decreases, most liver functions remain normal; however, drug metabolism is

impaired

Developmental Competence: The Aging Adult: inspection

increased deposits of subcutaneous fat on abdomen and hips because it is redistributed away from extremities

In the aging adult, incidence of gallstones

increases

umbilical hernia

protrusion of the intestine through a weakness in the abdominal wall around the umbilicus (navel)

Blumberg's sign

rebound tenderness

In the aging adult, the abdominal wall musculature

relaxes

kidneys

retroperitoneal (or behind the peritoneal cavity along the posterior abdominal wall.

peritoneal friction rub

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

hypogastric or suprapubic region

when the abdomen is divided into nine regions, the lower middle region

Objective Data: preparation

- Adequate lighting - Expose abdomen so that it is fully visible; drape genitalia and female breasts - Position for comfort to enhance abdominal wall relaxation - Empty bladder prior to examination with specimen saved if needed - Warm stethoscope and examine areas identified as painful last so as to prevent guarding - Auscultate prior to palpation and percussion - Use distraction to keep the patient relaxed and facilitate muscle relaxation

costovertebral angle

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

Bowel Sounds Note character and frequency of 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

Common causes of constipation 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 a person to deliberately retain stool until it becomes hard and difficult to pass

Percussion and Tympany

- Percuss general tympany, liver, and splenic dullness - To assess relative density of abdominal contents, to locate organs, and to screen for abnormal fluid or masses Yields highly variable results therefore not recommended -General tympany First, percuss lightly in all four quadrants to determine prevailing amount of tympany and dullness in clockwise manner

Costovertebral Angle Tenderness

- Positive finding indicates inflammation of the kidney - 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 A person normally feels thud but no pain -Its usual sequence in complete examination is with thoracic assessment, when the person is sitting up and you are standing behind

abdominal distention: feces

Inspection. Localized distention. Auscultation. Normal bowel sounds. Percussion. Tympany predominates. Scattered dullness over fecal mass. Palpation. Plastic-like or ropelike mass with feces in intestines.

Additional History for Aging Adults: Ask about

- access to groceries and food preparation - shared meals or eats alone - 24 hour dietary recall - swallowing or feeding difficulties - activities done following mealtimes. - bowel health—frequency, - constipation, fiber in your diet, - use of laxatives - medications—Rx and OTC

Palpate Surface and Deep Areas

-Judge size, location, and consistency of certain organs and screen for an abnormal mass or tenderness -Because most people are naturally inclined to protect abdomen, you need to use additional measures to enhance complete muscle relaxation -Begin with light palpation then proceed to deep palpation

To perform deep palpation use 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

Light and Deep Palpation With either technique, note location, size, consistency, and mobility of any palpable organs and presence of any abnormal enlargement, tenderness, or masses

-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

Auscultation of Bowel and Vascular Sounds This is done because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds

-Use diaphragm endpiece because bowel sounds are relatively high pitched -Hold stethoscope lightly against skin; pushing too hard may stimulate more bowel sounds -Begin in RLQ at ileocecal valve area because bowel sounds are normally always present here

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 to form an overall impression of skin surface and superficial musculature not to search for organs

Ascites

-free fluid in the peritoneal cavity) with distended abdomen, bulging flanks, and an umbilicus that is protruding and displaced downward -You can differentiate ascites from gaseous distention by performing -fluid wave test -shifting dullness test

abdominal distention: tumor

-inspection: localized distention -auscultation: normal bowel sounds -percussion: dull over mass if reaches up to skin surface -palpation: define borders, distinguish from enlarged organ or normally palpable structure

fluid wave test

-this tests for ascites by standing on the right side of the person-place the ulnar edge of another person's hand or patient's hand firmly in the middle of the abdomen-place your hands on the patient's right and left flank-give left flank a firm strike -if ascites is present a wave will generate through abdomen & you will feel a distant tap on your left hand -a positive test occurs with large amounts of ascitic fluid if distention is due to gas or adipose tissue=no change

clinical portrait of intestinal obstruction

1. history of previous abdominal surgery with adhesions, 2. vomiting, 3. absence of stool or gas passage, 4. distended abdomen (after 2nd day), 5. x-ray shows dilated air-filled loops of small bowel with multiple air-fluid levels. 6. hyperactive bowel sounds in early obstrction; hypoactive or silent in late obstruction. 7. dehydration and loss of electrolytes, 8. accumulation of fluid and gas in bowel proximal (above) to obstruction. 9. colicky pain from strong peristalsis above the obstruction. 10. fever. 11. pressure from excess fluid and gas may lead to leaking fluid into peritoneum 12. hypovelemic shock (decreased BP, increased pulse, cool skin if left untreated)

Inspection of the abdomen: Demeanor

A comfortable person is relaxed quietly on examining table and has a benign facial expression and slow, even respirations

incisional hernia

A type of hernia caused by an incompletely-healed surgical wound

aortic aneurysm

A weakness in the wall of the aorta that makes it susceptible to rupture.

Inspection of the Abdomen: symmetry

Abdomen should be symmetric bilaterally

Developmental Competence: The Aging Adult: Peristalsis

Abdominal musculature is thinner and has less tone than that of younger adult, so in absence of obesity you may note Because of thinner, softer abdominal wall, organs may be easier to palpate, in the absence of obesity

enlarged liver

An enlarged, smooth, nontender liver occurs with fatty infiltration, portal obstruction or cirrhosis, high obstruction of inferior vena cava, and lymphocytic leukemia. The liver feels enlarged and smooth but is tender to palpation with early heart failure, acute hepatitis, or hepatic abscess.

enlarged gallbladder

An enlarged, tender gallbladder suggests acute cholecystitis. Feel it behind the liver border as a smooth and firm mass like a sausage, although it may be difficult to palpate because of involuntary rigidity of abdominal muscles. The area is exquisitely painful to fist percussion, and inspiratory arrest (Murphy sign) is present. An enlarged, nontender gallbladder also feels like a smooth, sausagelike mass. It occurs when the gallbladder is filled with stones, as with common bile duct obstruction.

spleen

An organ that is part of the lymphatic system; it produces lymphocytes, filters the blood, stores blood cells, and destroys old blood cells.

Subjective Data

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

vascular sounds

Arterial:Bruit-indicates turbulent blood flow, as found in constricted, abnormally dilated, or tortuous vessels.

celiac disease

Autoimmune disorder Intolerant of gluten

enlarged spleen

Because any enlargement superiorly is stopped by the diaphragm, the spleen enlarges down and to the midline. When extreme, it can extend down to the left pelvis. It retains the splenic notch on the medial edge. When splenomegaly occurs with acute infections (mononucleosis), it is moderately enlarged and soft, with rounded edges. When the result of a chronic cause, the enlargement is firm or hard, with sharp edges. An enlarged spleen is usually not tender to palpation; it is tender only if the peritoneum is also inflamed.

is the sound of hyper peristalsis

Borborygmus

Dysphagia: Ask about

any difficulty in swallowing onset and associated symptoms

Inspection of abdomen: contour

Determine profile from rib margin to pubic bone; contour describes nutritional state and normally ranges from flat to rounded

enlarged kidney

Enlarged with hydronephrosis, cyst, or neoplasm. May be difficult to distinguish an enlarged kidney from an enlarged spleen because they have a similar shape. Both extend forward and down. However, the spleen may have a sharp edge, whereas the kidney never does. The spleen retains the splenic notch, whereas the kidney has no palpable notch. Percussion over the spleen is dull, whereas over the kidney it is tympanitic because of the overriding bowel.

Past abdominal history: Ask about

GI disease/pathology GI diagnostic procedures GI surgeries and clinical response

right lower quadrant

cecum, appendix, right ovary and tube, right ureter, and right spermatic cord.

Abdominal distention: obesity

Inspection. Uniformly rounded. Umbilicus sunken (it adheres to peritoneum, layers of fat are superficial to it). Auscultation. Normal bowel sounds. Percussion. Tympany. Scattered dullness over adipose tissue. Palpation. Normal. May be hard to feel through thick abdominal wall.

abdominal distension: Ascites

Inspection: single curve, inverted umbilicus. Ausculation: normal bowel sounds over intestines. Diminished over ascitic fluid. Percussion: Tympany at the top where intestines float. Dull over fluid. Produces fluid wave and shifting dullness.

abdominal distension: pregnancy

Inspection: single curve. Umbilicus protruding. Breasts engored. Ausculation: fetal heart tones. Bowel sounds diminished. Percussion: tympany over intestines. Dull over enlarging uterus. Palpitation: Uterine fundus, fetal parts, fetal movements

spleen's location

It lies obliquely with its long axis behind and parallel to the 10th rib, lateral to the midaxillary line. Its width extends from the 9th to the 11th rib, about 7cm.

Lactose intolerance

Lactase is a digestive enzyme necessary for absorption of carbohydrate lactose (milk sugar) These people are lactose intolerant and have abdominal pain, bloating, and flatulence when milk products are consumed Ethnic variation seen Estimated incidence of lactose intolerance is 20% to 30% of whites, 70% of Mexican Americans, and 80% of blacks and 100% American Indians

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

hyperactive bowel sounds

Loud, gurgling sounds, "borborygmi," signal increased motility. They occur with early mechanical bowel obstruction (high-pitched), gastroenteritis, brisk diarrhea, laxative use, and subsiding paralytic ileus.

Do not use auscultation for initial placement of

NG tube Evidence-based practice (EBP) confirming initial placement by imaging study and continued assessment by external tube length and pH of stomach aspirate

Inspection of the abdomen: umbilicus

Normally it is midline and inverted, with no sign of discoloration, inflammation, or hernia

Inspection of the Abdomen: pulsation or movement

Normally you may see pulsations from aorta beneath skin in epigastric area, particularly in thin persons with good muscle wall relaxation

Murphy's sign

Pain with palplation of gall bladder (seen with cholecystitis)

left lower quadrant

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

Inspection of the Abdomen: Hair distribution

Pattern of pubic hair growth normally has diamond shape in adult males and an inverted triangle shape in adult females

epigastric hernia

Protrusion of abdominal structures presents as a small, fatty nodule at epigastrium in midline, through the linea alba. Usually one can feel it rather than observe it. May be palpable only when standing.

Medications: Ask about

Rx and OTC alcohol—type, amount, and frequency smoking history

pancreas

Soft, lobulated gland located behind the stomach. It stretches obliquely across the posterior abdominal wall to the left upper quadrant.

Inspection of the abdomen: skin

Surface smooth and even, with homogeneous color; assess skin turgor Inspect for pigment change and presence of lesions or scars

shifting dullness test

Test for ascites: -Supine Position: percuss flanks from bed upward toward umbilicus -Side Position: percuss from bed upward toward umbilicus -In both positions note spot of change from dullness to tympany Normal: Sounds consistent with position change Abnormal (Indication of Ascites): Supine Position - Fluid assumes dependent position so dullness is heard at flanks and tympany around umbilicus. Side - Fluid assumes dependent position and air rises, so dullness is towards bottom and tympany towards top

aorta

The large arterial trunk that carries blood from the heart to be distributed by branch arteries through the body.

solid viscera

Those that maintain a characteristic shape. Liver, pancreas, spleen, adrenal glands, kidneys, ovaries, uterus

succussion splash

Unrelated to peristalsis, this is a very loud splash auscultated over the upper abdomen when the infant is rocked side to side. It indicates increased air and fluid in the stomach, as seen with pyloric obstruction or large hiatus hernia.

Developmental Competence: The Aging Adult Liver and kidneys are easier to palpate

With distended lungs and depressed diaphragm, liver can be palpated lower, descending 1 to 2 cm below costal margin with inhalation

As you listen to abdomen, note the presence of any vascular sounds or

bruits Small percentage of healthy people may have a bruit

In the aging adult, salivation decreases, leading to a dry mouth and

decreased sense of taste

Abnormal bowel sounds: hypoactive

decreased, can follow abdominal surgery or with inflammation

Nutritional assessment: Ask about

dietary history

hypoactive bowel sounds

diminished or absent bowel sounds signal decreased motility as a result of inflammation as seen with peritonitis; from paralytic ileus as following abdominal surgery; or from late bowel obstruction. Also occurs with pneumonia.

abdomen

large, oval cavity extending from the diaphragm down to the brim of the pelvis

right upper quadrant

liver, gallbladder, duodenum, head of pancreas, right kidney and adrenal, hepatic flexure of colon, part of ascending and transverse colon

normally palpable structures in abdomen

liver, kidneys (only right kidney), aorta, (bladder only if full)

epigastric region

located above the stomach

Abnormal bowel sounds: Hyperactive

loud, high-pitched signal increased motility

enlarged nodular liver

occurs with late portal cirrhosis, metastatic cancer, or tertiary syphilis

Pain: Ask about

onset, duration, location and severity characteristics (quality and pattern) and associated symptoms with regard to eating, pain getting worse or better association with any other clinical symptoms alleviating factors and aggravating factors treatment methods: Rx and OTC

Bowel habits: Ask about

onset, frequency, type and amount associated symptoms and/or triggers recent foods eaten and/or travel habits

Nausea and Vomiting: Ask about

onset, frequency, type and amount associated symptoms and/or triggers recent foods eaten and/or travel habits

greater omentum

part of the peritoneum attached to the stomach and to the colon and covering the intestines

hollow viscera

stomach, gallbladder, small intestine, colon, bladder

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

peritoneum

the membrane that lines the abdominal cavity and covers the organs within it

Umbilical region contains

transverse colon of large intestine, small intestine

Food intolerance: Ask about

type of food reaction that occurs use of Rx or OTC medication—amount and frequency

Common Sites of Referred Abdominal Pain

•Liver—RUQ •Esophagus—behind lower sternum •Ulcer—shoulder •Gallbladder—RUQ •Appendix—RLQ •Pancreas—Midscapular •Kidney—flank pain •Small intestine—diffuse •Colon—colicky pain and bloating