Abdominal Assessment- HA Ch. 21

Black stools

may be tarry due to occult blood (melena) from GI bleeding or non- tarry from iron medications

Spleen

On posterolateral wall of abdominal cavity, immediately under diaphragm. Lies obliquely with its long axis behind and parallel to the 10th rib, lateral to the midaxillary line. Width extends from 9th to 11th rib (about 7 cm). If enlarged, its lower pole moves downward & toward the midline.

Older method of abdomen division

1) Epigastric region 2) Umbilical region 3) Hypogastric or suprapubic region

Palpation of Abdomen

- Measures to enhance muscle relaxation - 3 types of palpation: - Light - Deep - Bimanual - Normally Palpable Structures: - Liver (Usual or Hooking Technique) - Spleen (not doing in class) - Kidneys (not doing in class) - Aorta (not doing in class) - Note location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness or masses

Rome III Symptom Criteria for functional constipation

1) Reduced stool frequency (less than 3 bowel movements per week) 2) Straining, lumpy or hard stool 3) Feeling of incomplete evacuation 4) Feeling of anorectal blockage 5) Use of manual maneuvers

Subjective Data

1) Appetite 2) Dysphagia- Difficulty swallowing 3) Food intolerance 4) Abdominal Pain- Have them point to it 5) Nausea/ Vomiting 6) Bowel habits 7) Abdominal history 8) Medications- GI side effects 9) Nutritional Assessment- 24 hr recall (may need to do week-long recall for aging adult)

Types of Abdominal Pain

1. Visceral- from internal organ (dull, general, poorly localized) 2. Parietal- from inflammation of peritoneum (sharp, precisely localized, aggravated by movement) 3. Referred- from a disorder from another site 4. Acute pain- occurs with appendicitis, cholecystitis, bowel obstruction or perforated organ 5. Chronic pain- of gastric ulcers occurs usually on empty stomach

Midline of Abdomen

Aorta Uterus (if enlarged) Bladder (if distended)

Rebound Tenderness (Blumberg Sign)

Assess when person reports abdominal pain or when you elicit tenderness during palpation. Choose a site away from painful area. Hold your hand 90 degrees or perpendicular to 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 at end of exam. Pain on release of pressure confirms rebound tenderness (reliable sign of peritoneal inflammation).

Incisional Hernia

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

Ascites Findings

Distended abdomen, bulging flanks, and umbulicus that is protruding and displaced downward. Occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis and cancer.

Objective Data: Inspection of Abdomen

Contour (do at eye level) Symmetry (do at eye level) Umbilicus Skin- Includes turgor Pulsation or movement Hair distribution Demeanor

Bowel Sounds

Begin in RLQ at ileocecal valve. Note character and frequency. High- pitched, gurgling, cascading sounds occurring irregularly anywhere from 5-30 times per minute. State if present, hypoactive, normoactive, or hyperactive. Perfectly silent is abnormal; must listen for 5 minutes before deciding if completely absent ( generally only for pt with no bowel motility)

Hematemesis

Blood in vomit; occurs with stomach or duodenal ulcers and esophageal varices

Auscultation of Abdomen

Bowel Sounds Vascular Sounds (bruits)

Right Lower Quadrant (RLQ)

Cecum Appendix Right ovary & tube Right ureter Right spermatic cord

Lactose Inotolerance

Decreased lactase levels cause abdominal pain, bloating, flatulence when milk products are consumed. More common in African Americans.

When should you not use auscultation of abdomen?

For correct placement of nasogastric feeding tubes bc auscultation of air bolus is not adequate to determine placement in stomach or lung

Percussion of Abdomen

General Tympany Liver Span (Usual technique; scratch test) Splenic dullness Costovertebral angle (CVA) tenderness Special Procedures (fluid wave; shifting dullness)

Rectus Abdominis muscles

Extends the length of the midline of the abdomen & its edge is often palpable. Muscles protect and hold the organs in place & flex the vertebral column

Shifting Dullness: Test for Ascites

In supine person, ascitic fluid settles by gravity into flanks, displacing the air-filled bowel to the periumbilical space. You will hear a tympanic note as you percuss over the top of abdomen bc gas-filled intestines float over fluid. Then, percuss down side of abdomen. If fluid is present, the note will change from tympany to dull ad you reach its level. Mark this spot. Turn person onto right side, percuss upper side of abdomen and move down. Sound changes from tympany to dull as you reach fluid level, but this time the fluid level is higher. Only positive w/ large volume of ascitic fluid.

Costovertebral angle tenderness

Indirect fist percussion in CVA on posterior abdomen. Place one hand over 12th rib at costovertebral angle. Thump hand with ulnar edge of other fist. Person normally feels thud but no pain. Sharp pain occurs with inflammation of kidney or paranephric area.

Steps of Abdominal Assessment

Inspection Auscultation- listen to all 4 quadrants Percussion Palpation- last bc it can hurt & make pt feel uncomfortable

Abnormal Findings: Ovarian Cyst (Large)

Inspection: Curve in lower half of abdomen, midline. Everted umbilicus. Auscultation: Normal bowel sounds over upper abdomen where intestines pushed superiorly Percussion: Top dull over fluid. Large cyst produces fluid wave and shifting dullness. *Palpation: Transmits aortic pulsation, whereas ascites does not*

Abnormal Findings: Ascites

Inspection: Single curve, everted umbilicus, bulging flanks when supine, taut & glistening skin, recent weight gain Auscultation: Normal bowel sounds over intestines. Diminished over ascitic fluid Percussion: Tympany at top where intestines float. Dull over fluid. Produces fluid wave & shifting dullness Palpation: Taut skin and increased intra-abdominal pressure limit palpation

Abnormal Findings: 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

Abnormal Findings: Feces

Inspection: localized distention Auscultation: Normal bowel sounds Percussion: Tympany predominates; scattered dullnessover fecal mass Palpation: Plastic-like or ropelike mass with feces in intestines

Abnormal Findings: Pregnancy

Inspection: single curve, protruding umbilicus, breasts engorged Auscultation: Fetal heart tones; bowel sounds diminished Percussion: Tympany over intestines; dull over enlarging uterus Palpation: Fetal parts; fetal movements

Abnormal Findings: Air or Gas

Inspection: single round curve Auscultation: Depends on cause of gas- decreased or absent bowel sounds with ileus; hyperactive with early intestinal obstruction Percussion: Tympany over large area Palpation: May have large spasm of abdominal wall

Abnormal Findings: Obesity

Inspection: uniformly rounded, umbilicus sunken Auscultation: Normal bowel sounds Percussion: Tympany; scattered dullness over adipose tissue Palpation: Normal. May be hard to feel through thick abdominal wall.

Viscera

Internal organs of abdominal cavity

Digestive enzyme necessary for absorption of carbohydrate lactose (milk sugar)

Lactase: in some racial groups lactase activity declines to low levels by adulthood. Children are more able to tolerate lactose than adults (bc they have higher levels of lactase).

Protuberant abdomen occurs with

Late pregnancy, severe obesity and ascites

Aorta

Left of midline in upper part of abdomen. Descends behind peritoneum & 2 cm below the umbilicus it bifurcates into right and left common iliac arteries opposite the 4th lumbar vertebra. Can palpate aortic pulsations easily in the upper anterior abdominal wall.

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

Usual Technique of Palpating Liver

Liver in RUQ. Place left hand under person's back parallel to 11th and 12th ribs and lift up to support abdominal contents. Place right hand on RUQ with fingers parallel to midline. Push deeply down and under right costal margin. Ask person to breathe slowly and with every exhalation, move your palpating hand up 1 or 2 cm. It is normal to feel edge of liver bump your fingertips as diaphragm pushes it down during inhalation (feels like a firm, regular ridge). Often, the liver is not palpable.

Liver span in patients with chronic emphysema

Liver is displaced downward by hyperinflated lungs. Overall span should still be in normal limits.

Solid Viscera

Liver, pancreas, spleen, adrenal glands, kidneys, ovaries, and uterus

In regards to the abdominal quadrants, where is the small intestine located?

Located in all 4 quadrants

Percussion: Liver Span- Usual Technique

Measure height of liver in right MCL. Begin in area of lung resonance (under breast) and percuss down IC spaces until sound changes to dull & mark spot (usually in 5th IC space). Then, start at umbilicus and percuss up in MCL, where sound changes from tympany to dull and mark. Measure distance bw two marks; normal liver span is 6-12 cm. Taller ppl have longer livers. Males have longer liver span than females of same height. Screens for hepatomegaly and monitors changes in liver size.

Diastasis Recti

Midline longitudinal ridge that is a separation of the abdominal rectus muscles. Ridge is revealed when intra-abdominal pressure is increased by raising head while supine. Occurs congenitally, and as a result of pregnancy or marked obesity in which prolonged distension or a decrease in muscle tone has occurred. Not clinically significant.

Infants & Children: Abdomen

More prominent umbilicus. Liver is easily palpated bc it takes up more space in abdomen at birth. Urinary bladder is located higher in the abdomen, so if the baby has a bladder infection, then symptoms will be higher up. Also, organs will be easier to palpate bc abdominal wall is less muscular

The Pregnant Woman: Abdomen

Morning sickness bc of hormonal changes like production of hCG. "Acid indigestion" or heartburn (pyrosis) caused by esophageal reflux. Progesterone also causes heartburn. GI motility decreases which causes more water to be absorbed from the colon, causing constipation. Constipation + increased venous pressure in lower pelvis may lead to hemorrhoids. Enlarging uterus displaces intestines and diminishes bowel sounds.

Umbilicus Assessment

Normal: Midline & inverted with no sign of discoloration, inflammation or hernia. Becomes everted and pushed upward with pregnancy and umbilical hernia. Bluish periumbilical color occurs with intraperitoneal bleeding (Cullen sign).

Pulsation or Movement on Abdomen

Normal: See pulsations from aorta in epigastric area. Respiratory movement shows in abdomen; especially in males. Waves of peristalsis can be seen in very thin ppl. Marked visible peristalsis with distended abdomen indicates intestinal obstruction.

Striae

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. They look purple-blue with Cushing syndrome.

Red blood in stools

Occurs with GI bleeding or localized bleeding around the anus

Enlarged nodular liver

Occurs with late portal cirrhosis, metastatic cancer, or tertiary syphilis. Often with cirrhosis the liver is smaller, but the edge is firmer than normal and the edge is easily palpable.

Left Lower Quadrant (LLQ)

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

Percussion: General Tympany

Percuss lightly in all 4 quadrants to determine amt of tympany and dullness. Move clockwise. Tympany is predominate bc air in intestines rises to surface when person is supine. Hyperresonance is present with gaseous distension. Dullness occurs over distended bladder, adipose tissue, fluid or a mass. Percuss in 2 different spots in each quadrant of abdomen.

Positioning of Patient for Abdominal Exam

Position person supine, with head on pillow, knees bent or on pillow, and arms at sides or across chest (don't put arms above head bc this tenses abdominal musculature). Can also place pillow under knees to relax abdominal muscles. Use table leaf.

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.

Aging Adult: Abdomen

Relaxation of abdominal muscles bc of accumulation of adipose tissue (decreases motility). Salivation decreases, decreased taste, esophageal emptying is delayed, gastric acid secretion decreases, liver size decreases which impairs drug metabolism bc blood flow through liver and liver size are decreased. Many older ppl complain of constipation & more frequent incidences of gallstones.

Kidneys

Retroperitoneal or posterior to the abdominal contents. Well protected by posterior ribs and musculature. Left kidney lies in costovertebral angle. Right kidney is 1 to 2 cm lower than the left kidney bc of liver.

Symmetry of Abdomen

Shine light across abdomen toward you or lengthwise across person. Note any localized bulging, visible mass or asymmetric shape. Even small bulges are highlighted by shadow. Ask person to take a deep breath to further highlight any change.

Demeanor

Should be nonpainful in Comfortable person: relaxed, benign facial expression and slow, even respirations. Restlessness & constant turning to find comfort occur with colicky pain of gastroenteritis or bowel obstruction. Absolute stillness occurs with pain of peritonitis. Knees flexed up, facial grimacing, and rapid, uneven respirations also indicate pain.

Umbilical Hernia

Soft, skin-covered mass. Protrusion of omentum or intestine through a weakness or incomplete closure in umbilical ring. More common in premature infants. Most resolve spontaneously by 1 year. In adult, occurs with pregnancy, chronic ascites, or chronic intrathoracic pressure (asthma, chronic bronchitis).

Fluid Wave: Test for Ascites

Stand on person's right side. Place ulnar edge of another examiner's hand or pt's own hand firmly on abdomen in midline (this stops transmission across skin of upcoming tap). Place left hand on person's right flank. With right hand, reach across abdomen and give left flank a firm strike. If ascites is present, the blow will generate a fluid wave through abdomen and you will feel a distinct tap on your left hand.

Hooking Technique of Palpating Liver

Stand up at person's shoulder and swivel your body to the right so you face the person's feet. Hook your fingers over the costal margin from above. Ask person to take a deep breath and try to feel the liver edge bump your fingertips.

Equipment Needed for Abdominal Assessment

Stethoscope Small cm ruler Skin- marking pen Alcohol swab

Left Upper Quadrant (LUQ)

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

Hyperperistalsis Bowel Sounds

Stomach growling: borborygmus

Hollow viscera

Stomach, gallbladder, small intestine, colon and bladder. The shape depends on their contents. Usually not palpable.

Enlarged gallbladder

Suggests acute cholecystitis. Feel it behind liver border as a smooth and firm mass like a sausage ( may be difficult to palpate bc of involuntary rigidity of abdominal muscles). Area is exquisitely painful to fist percussion and inspiratory arrest (Murphy sign) is present. Enlarged, nontender gallbladder also feels like a smooth, sausagelike mass. Occurs when gallbladder is filled with stones.

Skin on Abdomen

Surface is smooth and even with homogeneous color. Good area to judge pigment bc it's often protected from sun. Striae (lineae albicantes) are common in obesity & pregnancy- silvery white, linear jagged marks about 1-6 cm long. Pigmented nevi are common. If scars are present, document location and length in cm. Skin is glistening and taut and striae occur with ascites.

Vascular Sounds (Bruits)

Use firmer pressure & check over aorta, renal arteries, iliac and femoral arteries, especially in ppl with hypertension. Usually not present. In 4- 20% of healthy ppl, a normal bruit originates from celiac artery (systolic, medium to low pitch & heard bw xiphoid process and umbilicus). Note location, pitch & timing of vascular sound.

Light palpation

Use first four fingers close together and depress skin about 1 cm. Use gentle rotary motion, sliding fingers & skin together. Lift fingers and move clockwise to next location. Forms an overall impression on skin surface and superficial musculature. Discriminate bw voluntary muscle guarding and involuntary rigidity.

Deep palpation

Use same technique described for light palpation, but push down about 5-8 cm (2-3 in). Move clockwise around abdomen.

Bimanual palpation

Use two hands (placed on top of each other) for very large or obese abdomen. Top hand does pushing.

Normally Palpable Structures on Abdomen

Xiphoid Process Normal liver edge Right kidney, lower pole Pulsatile aorta Rectus muscles, lateral borders Sacral promontory Ascending colon Cecum Sigmoid colon- mild tenderness is normally present Uterus (if gravid) Full Bladder

Obesity

accumulation of excess body fat. More African American women are obese when compared to Caucasian women.

Involuntary rigidity

constant, boardlike hardness of muscles. It's 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.

The 12th rib forms an angle with the vertebral column called the _________________________.

costovertebral angle; left kidney lies here at the 11th and 12th ribs

Enlarged liver

enlarged, smooth, nontender liver occurs with fatty inflitration, portal obstruction or cirrhosis, high obstruction of inferior vena cava, and lymphocytic leukemia. Liver is tender to palpation with early heart failure, acute hepatitis or hepatic abcess

Except with a depressed diaphragm, a liver palpated more than 1 to 2 cm below the right costal margin is ______________.

enlarged; record number of cm it descends and note its consistency and tenderness

Liver

fills most of RUQ and extends over to the left MC line.

Hypoactive bowel sounds

follow abdominal surgery or with inflammation of peritoneum; also occurs with pneumonia.

What does peptic ulcer disease occur with?

frequent use of nonsteroidal antiinflammatory drugs (NSAIDs), alcohol, smoking and Helicobacter pylori infection

Sister Mary Joseph nodule

hard nodule in umbilicus that occurs with metastatic cancer of stomach, large intestine, ovary or pancreas.

Pyrosis

heartburn; burning sensation in esophagus and stomach from reflux of gastric acid

Hyperactive bowel sounds

loud, high- pitched, rushing, tinkling sounds that signal increased motility (borborygmi); occur with early mechanical bowel obstruction, gastroenteritis, brisk diarrhea, laxative use and subsiding paralytic ileus

Voluntary guarding

occurs when person is cold, tense or ticklish. It's bilateral, and you will feel the muscles relax slightly during exhalation. If rigidity persists. it is probably involuntary.

Prominent, dilated veins on abdomen occur with

portal hypertension, cirrhosis, ascites or vena caval obstruction

Hernia

protrusion of abdominal viscera through abnormal opening in muscle wall

Systolic bruit

pulsatile blowing sound & occurs with stenosis or occlusion of artery

Contour of Abdomen

stand at person's right side and look down at abdomen. Then, stoop down to observe at eye level. Determine profile from rib margin to pubic bone. Contour describes nutritional state and normally ranges from flat to rounded. Others include scaphoid (caves in) and protuberant.