Ch 21 - Abdomen

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 the stomach

cholecystitis

inflammation of the gallbladder

peritonitis

inflammation of the peritoneum

viscera

internal organs

diastasis recti

midline longitudinal ridge in abdomen, separation of abdominal rectus muscles

linea alba

midline tendinous seam joining the abdominal muscles

expected examination findings of enlarged liver

feels enlarged and smooth; nontender with early HF, acute hepatitis or hepatic abscess

cecum

first or proximal part of large intestine

normoactive (bowel sounds)

high-pitched, gurgling, cascading, occur irregularly anywhere from 5-30x/min

tympany

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

bruit (bowel sounds)

pulsitile blowing sound

expected examination findings of appendicitis

rebound tenderness (positive Blumberg sign) and positive iliopsoa muscle test

peritoneal friction rub

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

palpation of the kidneys

(R) "duck bill" pt's right flank with Left hand posterior; press hands together firmly while pt takes deep breath (L) not usually palpable; similar to spleen but across flank, not ribs.

pyrosis

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

striae

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

palpation of the spleen

(stand on pt R side) L hand over abdomen, behind L side 11+12th ribs, lift for support; R hand obliquely with LUQ with fingers painting to L axilla, inferior to costal margin; ask pt to take deep breath or roll to R side

Inspection of the abdomen

*Contour:* flat, scaphoid, rounded, distended *Symmetry:* localized bulging, visible mass, asymmetric shape *Umbilicus (normal):* midline, inverted, no discoloration, no inflammation, no hernia *Umbilicus (abnormal):* everted with ascites, deeply sunken with obesity, enlarged and everted, bluish periumbilical *Skin (normal):* surface is smooth, even, homogenous in color (striae common with pregnancy and weight gain) *Skin (abnormal):* redness, jaundice, glistening with ascites, striae with ascites, purple-blue striae with cushings, !!note surgical scars, including length in cm *pulsation/movement (normal):* aorta pulsations, respiratory movement, peristalsis (especially if pt is thin) *pulsation/movement (abnormal):* marked pulsation, marked visible peristalsis *Hair distribution (abnormal):* altered pattern with endocrine or hormone issues *Demeanor:* should be comfortable, relaxed, benign expression; !!note pain/protective movement

costovertebral angle tenderness

- PT sitting up: indirect fist percussion; first hand over rib 12 at CVA on back; thump hand with ulnar edge of other fist - normal: pt feels thud, no pain - abnormal: sharp pain occurs with inflammation of kidney or paranephric area

costovertebral angle (CVA)

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

rigidity

- constant, board-like hardness of muscles - may be unilateral - same area usually becomes painful with increase of abdominal pressure (like sitting up)

abnormalities detected by deep palpation

- enlarged organs - tenderness - masses

Changes with aging

- increased deposits of subQ fat on abdomen and hips as it is redistributed away from extremities - abd musculature is thinner and has less tone - in absence of obesity: organs may be easier to palpate; peristalsis may be easier to see - liver easier to palpate - with distended lungs and depressed diaphragm, liver is palpated lower (descending 1-2cm below costal margin with inhalation) - kidneys easier to palpate * abd rigidity with acute abd conditions is less common in aging; with acute abd, pt often complains of less pain than younger pt

abnormalities detected by light palpation

- involuntary rigidity - muscle guarding - large masses - tenderness

organs normally palpable in abdomen

- lower edge of liver - right kidney - ovaries (bimanual exam) - colon (distended with feces) - bladder (distended with urine) * can also palpate aortic pulses

voluntary guarding

- occurs when pt is cold, tense or ticklish - bilateral - muscles relax slightly on exhale

Significance of red blood in stool

- occurs with GI bleeding (in lower GI tract) or localized bleeding around the anus (as with hemorrhoids)

rebound tenderness (Blumberg Sign)

- pain on release of pressure as organs rebound suddenly after being indented - RN pushes on a site away from pain with hand at 90* -- slow push, fast pull off

Iliopsoas muscle test

- performed when acute abdominal pain of appendicitis is suspected - pt supine; lift right leg straight up, flexing at the hip - push dwon over the lower part of the right thigh as the pt tries to hold leg up - negative: pt feels not change - positive: iliopsoas muscle is inflamed (occurs with inflamed or perforated appendix), pain is felt in RLQ

shifting dullness

- pt in supine position; stand on pt's right side - percuss over top of abdomen and down side - mark where dullness begins - roll pt toward you, on their right side - repeat percussion and mark where dullness begins - shifting level indicates fluid.

proper positioning and preparation of the patient for abdominal examination

- pt should have empty bladder - supine position, head on pillow, knees bent (or on pillow), arms at side or across chest

tympany (percussion notes heard over abdomen)

- should predominate - air in intestines rises to surface when patient is supine

fluid wave test

- stand on pt's right side - place ulnar edge of pt's hand firmly on abdomen in midline (to stop transmission of strike across skin); - Place left hand on pt's right flank and give pt's left flank a firm strike - if ascites, blow will generate fluid wave through abdomen and tap will be felt by left hand - if gas or adipose = no change.

deep palpation

- use same technique as light palpation but push 5-8cm (2-3in) - use bimanual technique for large/obese patients - when using bimanual technique - push with top hand and feel with bottom hand!!! - note location, size, consistency and mobility of palpable organs plus presence of abnormal enlargement, tenderness or masses

succession splash (bowel sounds)

- very loud splash over upper abdomen when infant rocked side to side, unrelated to peristalsis - indicates increased air and fluid in the stomach, as seen w/ pyloric obstruction or large hiatus hernia

somatic (parietal) pain

BV, joint, tendon, muscle and bone pain

expected examination findings of tumor

I: localized distention A: normal bowel sounds PC: dull over mass if reaches skin surface PA: define borders + distinguish from organs

expected examination findings of ascites

I: single curve, everted umbilicus, flanks bulge at supine; taut glistening skin, increased weight, increased abdominal girth A: normoactive over GI, dull over ascitic fluid PC: tympany at top where intestines float, dull over fluid; fluid wave shift and shifting dullness PA: taut skin, increased intra-abdominal pressure -- limit palpation

expected examination findings of pregnancy

I: single curve, umbilicus protruding, breasts engorged A: fetal heart tones, decreased bowel sounds PC: tympany over intestines, dull over enlarging uterus PA: fetal parts and movements

expected examination findings of gaseous distention

I: single, round curve A: depends on reason: decrease or absent with ileus; increase with early intestinal obstruction PC: tympany over large area PA: may have muscle spasm of abdominal walls

expected examination findings of obese pt

I: uniformly rounded, sunken umbilicus A: normal bowel sounds PC: tympany; scattered dullness over adipose PA: normal, may be difficult to feel

Inspiratory Arrest (Murphey Sign)

Normal: palpation of liver causes no pain Inflamed gallbladder: pain occurs; - Hold fingers under liver border, ask pt to take deep breath. Normal response is to complete breath without pain. When the test is positive, as the descending liver pushes the inflamed gallbladder onto examining hand, pt feels sharp pain and abruptly stops inspiration midway. ((less accurate for pt over 60 - 1/4 of them have no tenderness)

procedure for auscultation of bowel sounds

Start in RLQ at ileocecal valve (bowel sounds almost always present here) and move clockwise.

expected examination findings of enlarged spleen

acute infection: moderately large and soft chronic cause: firm or hard with sharp edges, - usually nontender; only tender with inflamed peritoneum

Auscultation of the abdomen is begun in the right lower quadrant because: a) bowel sounds are always normally present here b) peristalsis through the descending colon is usually active c) this is the location of the pyloric sphincter d) vascular sounds are best heard in this area

a

Auscultation of the abdomen may reveal bruits of the __________ arteries. a) aortic, renal, iliac, and femoral b) jugular, aortic, carotid, and femoral c) pulmonic, aortic, and portal d) renal, iliac, internal jugular, and basilic

a

Right upper quadrant tenderness may indicate pathology in the: a) liver, pancreas, or ascending colon b) liver and stomach c) sigmoid colon, spleen, or rectum d) appendix or iliocecal valve

a

Shifting dullness is a test for: a) ascites b) splenic enlargement c) inflammation of the kidney d) hepatomegaly

a

ascites

abnormal accumulation of serous fluid within the peritoneal cavity, associated with CHF, cirrhosis, caner, or portal HTN

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

Murphy sign is best described as: a) the pain felt when the hand of the examiner is rapidly removed from an inflamed appendix b) pain felt when taking a deep breath when the examiner's fingers are on the approximate location of the inflamed gallbladder c) a sharp pain felt by the patient when one hand of the examiner is used to thump the other at the costovertebral angle d) not a valid examination technique

b

Procedure for percussing liver span

begin percussing R midclavicular line, being in lung resonance and work down (normally 5th ICS); mark the spot; move to abdominal tympany and work up; mark dull spot and measure in between

bruit

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

Select the sequence of techniques used during an examination of the abdomen. a) percussion, inspection, palpation, auscultation b) inspection, palpation, percussion, auscultation c) inspection, auscultation, percussion, palpation d) auscultation, inspection, palpation, percussion

c

Tenderness during abdominal palpation is expected when palpating: a) the liver edge b) the spleen c) the sigmoid colon d) the kidneys

c

The absence of bowel sounds is established after listening for: a) 1 full minute b) 3 full minutes c) 5 full minutes d) none of the above

c

Which of the following may be noted through inspection of the abdomen? a) fluid waves and abdominal contour b) umbilical eversion and Murphy Sign c) venous pattern, peristaltic waves, and abdominal contour d) peritoneal irritation, general tympany, and peristaltic waves

c

A dull percussion note forward of the left midaxillary line is: a) normal, an expected finding during splenic percussion b) expected between the 8th and 12th ribs c) found if the examination follows a large meal d) indicative of splenic enlargement

d

A positive Blumberg sign indicates: a) a possible aortic aneurysm b) the presence of renal arty stenosis c) an enlarged, nodular liver d) peritoneal inflammation

d

Hyperactive bowel sounds are: a) high pitched b) rushing c) tinkling d) all of the above

d

Striae, which occur when the elastic fibers in the reticular layer of the skin are broken after rapid or prolonged stretching, have a distinct color when of long duration. This color is: a) pink b) blue c) purple-blue d) silvery white

d

The left upper quadrant contains the: a) liver b) appendix c) left ovary d) spleen

d

The range of normal liver span in the right midvlavicular line in the adult is: a) 2-6cm b) 4-8cm c) 8-14cm d) 6-12cm

d

aneurysm

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

light palpation

depress ~1cm using gentle rotary motion, sliding skin and fingers together - form overall impression of skin surface and superficial musculature - note location, size, consistency and mobility of palpable organs plus presence of abnormal enlargement, tenderness or masses

dysphagia

difficulty swallowing

hypoactive (bowel sounds)

diminished

palpation of the liver

left hand behind the 11+12th ribs, R hand push under R costal margin (or hook hands under costal margin) ask pt to take deep breath

inguinal ligament

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

expected examination findings of distended bladder

localized distention

anorexia

loss of appetite for food

borborgymi

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

hyperactive (bowel sounds)

loud, high-pitched rushing, tinkling; (= increased motility)

costal margin

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

Significance of black stool

may be due to occult blood from GI bleeding (in upper GI tract); if non-tarry, may be from iron medication

rectus abdominis muscles

midline abdominal muscles extending from rib cage to pubic bone

epigastrium

name of abdominal region between costal margins

suprapubic

name of abdominal region just superior to the pubic bone

dullness (percussion notes heard over abdomen)

occurs over distended bladder, adipose tissue, fluid or a mass

visceral pain

pain originates from larger interior organs - pain signal sent along with ANS - often presents with vomiting, nausea, pallor and diaphoresis

Procedure for percussing spleen span

percuss for dullness at around 9-11ICS, just behind midaxillary line. Should not be wider than 7cm.

rationale for performing auscultation of abdomen before palpation or percussion

percussion and palpation can increase peristalsis which may give a false interpretation of bowel sounds

hyperresonance (percussion notes heard over abdomen)

present with gaseous distention