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.