Medicine

26. Abdomen Anatomy and Physiology

Abdomen: Anatomy and Physiology

 

After you have successfully completed this chapter, you should be able to:

 

·                    Identify pertinent abdominal history questions

·                    Obtain a pertinent abdominal history

·                    Perform an abdominal physical assessment

·                    Document abdominal assessment findings

·                    Identify actual/potential health problems stated as nursing

·                    diagnoses

·                    Differentiate between normal and abnormal findings

 

The abdominal assessment provides information about a variety of systems because every system, with the exception of the respiratory system, is found within the abdomen. The stomach, small and large intestines, liver, gallbladder, pancreas, spleen, kidneys, ureters, bladder, aortic vasculature, spine, uterus and ovaries, or spermatic cord are all located in the abdomen. Not only does assessment of the abdomen enable you to obtain valuable information about the functioning of the gastrointestinal (GI), cardiovascular, reproductive, neuromuscular, and genitourinary systems; it can also provide vital information about the health status of every other system. 

 

Anatomy and Physiology Review

 

Before you begin your assessment, an understanding of the anatomy and physiology of abdominal structures is essential. You must be able to recognize normal structures before you can identify abnormal findings. Recognizing the structures will enable you to perform the assessment accurately, and understanding the physiology will guide your assessment and allow you to interpret your findings.

 

 Structures and Functions

The major system assessed in the abdominal examination is the GI or digestive system. The digestive system is responsible for the ingestion and digestion of food,absorption of nutrients, and elimination of waste products. The primary structures of the digestive system (Fig. 17.1) include the mouth, pharynx, esophagus, stomach, small intestines (duodenum, jejunum, and ileum), large intestines (cecum, colon [ascending, transverse, descending, and sigmoid]), and rectum.These main structures of the digestive system form a hollow tube that is actually outside the internal environment of the body even though it is located inside the body.This tube, referred to as the alimentary canal or the gastrointestinal tract, begins at the mouth and ends at the anus. The digestive system also contains accessory organs that aid in the digestion of food. The accessory organs of the digestive system include the salivary glands (parotid, submandibular, and sublingual), liver, gallbladder, and pancreas. 

 




 



 

 

The Digestive Process

The digestive process consists of mechanical digestion, the breakdown of food through chewing, peristalsis, and churning; and chemical digestion, the breakdown of food through a series of metabolic reactions with enzymes. The digestive process begins in the mouth, where food is taken in and masticated. The bolus of food is then swallowed into the esophagus, where it is propelled slowly via peristaltic contraction to the stomach. In the stomach, the food bolus is churned, breaking it down further into smaller particles and mixing it with digestive juices and hydrochloric acid that is produced by the stomach.The food bolus becomes chyme and progresses down into the first portion of the small intestine, called the duodenum. In the duodenum, pancreatic juices and bile are secreted in the chyme. The food then enters the jejunum and ileum, where nutrients are absorbed into the circulatory system. Food particles that are not absorbed by the small intestines proceed into the large intestine, where they are eventually excreted as feces.

 

Additional Abdominal Structures

 

Along with the organs of the digestive system, the abdomen also contains the spleen; the urinary tract including the bladder, kidneys, and ureters; the uterus and ovaries; the aorta; and the iliac, renal, and femoral arteries. The uterus and ovaries are covered in Chapter 18,Assessing the Female Genitourinary System.The other abdominal organs are shown in Figure 17.2. The abdominal cavity has a serous membrane called the peritoneum, which covers the organs and holds them in place.The peritoneum contains a parietal layer that lines the walls of the abdomen and the visceral pleura, which coats the outer surface of the organs. A small amount of fluid between these membranes allows them to move smoothly within the cavity. 



 

Interaction With Other Body Systems

The GI system requires the proper functioning of the nervous, endocrine, respiratory, cardiovascular, integumentary, and musculoskeletal systems in order to operate at its full capacity.

 

The Integumentary and Musculoskeletal Systems

 

The digestive system is protected and supported by the musculoskeletal and integumentary systems.The musculoskeletal system also assists with ingestion, mastication, deglutition (swallowing) of food,and eventual defecation of its byproducts.

 

The Respiratory and Cardiovascular Systems

 

The respiratory and cardiovascular systems provide the oxygen needed for the digestive organs to function.The respiratory system gets oxygen for the cells of the body and rids the body of carbon dioxide. All the cells in the body, including those of the digestive system, need oxygen to function appropriately.The cardiovascular system circulates the oxygen-rich blood to all the cells in the body.Any decrease in oxygen to the cells of the digestive system affects organ function. For example, if blood flow to the bowel is disrupted,a bowel infarct can occur, causing the bowel to stop functioning.

 

The Neurological System

 

The neurological system plays an important role in digestion. When the body is in a parasympathetic response, or the “rest and repair” phase, the neurological system releases acetylcholine, the neurotransmitter for the parasympathetic system. In relation to the digestive system, acetylcholine stimulates the secretion of digestive juices and increases peristalsis. The opposite is true for the sympathetic response. The sympathetic system is stimulated at times of physical or psychological stress.When this system is stimulated, a “fight or flight” response occurs, causing the release of norepinephrine,which produces a decrease in peristalsis and secretion of digestive juices.Therefore, the digestive system functions to its maximum capacity when it receives parasympathetic responses from the peripheral nervous system.

 

The Endocrine System

 

The secretion of digestive juices also depends on the proper functioning of the pancreas, an organ that has both endocrine and exocrine functions. The endocrine function is to release insulin, glucagon, and gastrin into the bloodstream to assist in carbohydrate metabolism. The exocrine function is to secrete bicarbonate and pancreatic enzymes into the duodenum to aid in the digestion of proteins, fats, and carbohydrates.  

 

Performing the Abdominal Assessment

 

Assessment of the abdomen involves obtaining a complete health history and performing a physical examination. As you assess the patient, be watchful for signs and symptoms of actual and potential problems involving the different organs and structures in the abdomen.

 

Health History

 

The health history precedes the physical examination and involves interviewing the patient about his or her perception of his or her health status.The health history interview includes a broad range of questions so that possible problems associated with each of the systems of the abdomen may be identified. Remember that information collected as part of the health history may uncover problems related to systems outside the abdomen (e.g., myocardial infarction [MI]). If time is an issue and you are unable to perform a complete health history, perform a focused history on the abdomen.


 

Biographical Data

 

Gathering biographical information can provide valuable insights about the patient’s health status in several ways. Certain age groups are at greater risk for problems in the GI system. For example, infants and toddlers have a higher incidence of hernias than older children. Preschoolers are more likely to get parasitic infections, and teenagers may have abdominal symptoms as a result of pregnancy, sexually transmitted diseases (STDs),eating disorders like anorexia nervosa or bulimia, and infectious mononucleosis. Appendicitis occurs more frequently in children and teenagers than it does in adults. Older adults commonly develop problems with digestion, absorption, metabolism, and elimination because of changes caused by the aging process.Women aged 65 and over are commonly diagnosed with hiatal hernia, constipation, and diverticulosis. Certain diseases occur more frequently in some races and cultures (see previous section).You will need to ask additional health history questions to determine  whether symptoms of these diseases are present so that appropriate screening measures can be performed, if necessary. The potential for exposure to environmental and occupational hazards can also be discovered in the biographical data. Where a person lives or works may raise questions about environmental hazards such as lead exposure in children (from inhalation of lead-based paint dust in older houses) or occupational health hazards such as chemical exposure (arsenic, benzene). 

 

Current Health Status

If your patient has an abdominal complaint, investigate this first. Common chief complaints involving the body systems in the abdomen include:

·                    Lymphatic: Swelling, lymph node tenderness.

·                    Digestive: Anorexia, bruising, constipation, diarrhea, distension, dysphagia, epigastric burning, gastric reflux, indigestion, jaundice, nausea, vomiting, pain, weight changes.

·                    Reproductive: Cramping,nausea,pain,vomiting,weight gain.

·                    Neurological: Pain.

·                    Cardiovascular: Pain.  

·                    Urinary: Edema, pain, problems with urination (burning, frequency).  

 

The most common abdominal complaints—pain, changes in weight, changes in bowel habits (constipation, diarrhea), indigestion, nausea, and vomiting—are analyzed in the subsequent text,using the PQRST format. The nature and intensity of the symptoms dictate the order and extent of questioning during the symptom analysis.

 Symptom Analysis

Symptom analysis tables for all the symptoms described in the following paragraphs are available for viewing and printing on the compact disc that came with the book.

 Abdominal Pain

The most common complaint related to the abdomen, pain is often classified as visceral, parietal, or referred.

Visceral pain results from distension of the intestines or stretching of the solid organs. It is often described as burning, cramping, diffuse, and poorly localized.

Parietal pain results from inflammation of the parietal peritoneum. The pain is usually severe, localized, and aggravated by movement.

Referred pain is felt at a site away from the site of origin. Impulses from the internal organs and structures that share nerve pathways inside the central nervous system explain the nature of referred pain. Acute abdominal pain (“acute abdomen”) may indicate a life-threatening abdominal condition that requires immediate medical intervention. In this situation, you should assess the patient’s vital signs to determine whether she or he is in imminent danger.Vital signs provide information about the possibility of cardiac irregularities and reveal symptoms of shock and signs of an infectious process such as peritonitis. In addition, you need to prioritize the symptom assessment questions to elicit the most essential information.The order of symptom assessment becomes RTQSP.

 

 Pain Location

The location of the pain is often diagnostically significant. Some disorders have classic signs located in specific regions of the abdomen. For instance, pain in the umbilical region may indicate an abdominal aortic aneurysm or early appendicitis. Abdominal problems may also cause referred pain to the chest, so chest pain can indicate either an abdominal problem or a cardiac event. Patients with a gastric ulcer can have pain in the upper epigastric region left of midline, which is also the location for angina and MI. Patients with gastroesophageal reflux disease (GERD) may have chest pain that radiates to the back, neck, or jaw, which also mimics an MI. Patients with a hiatal hernia may complain of substernal chest pain and difficulty breathing, especially after a meal.

 

Note location of pain by quadrant or region:

 

Pain in shoulder: Ruptured spleen, ectopic pregnancy, Pancreatitis.

Pain in scapula: Cholelithiasis, MI, angina, biliary colic, pancreatitis.

Pain in thighs, genitals, lower back: Renal problems, ureteral colic.

Pain in lower and middle back: Abdominal aortic aneurysm. Recognizing the relationship between the location of the pain and the possible health problem has important implications for immediate nursing assessment and care of the patient.  

 


 


 

Change in Bowel Patterns

 

Alterations in bowel movements are associated with a variety of GI disorders, such as malabsorption disorders, irritable bowel syndrome, cancer, infections (viral, bacterial, parasitic), food intolerance, and reactions to medications, as well as non-GI disorders.To determine whether a patient is having health problems that affects bowel function, first establish a baseline by asking general questions about bowel habits, such as: “How often do you have bowel movements? Do you have any problems with your bowels, such as straining, pain, constipation, or diarrhea?” Then ask more specific questions to help identify the origin of the problem.

 Bowel patterns range from two movements per day to two or three per week. Identify the color of the stool:

Black, tarry: Upper GI bleeding.

Red, bloody: Lower GI bleeding.

Clay colored: Increased bile in obstructive jaundice.

 

Weight Change

 

Weight change may indicate diseases in many body systems, reflect unhealthy behaviors, or even reveal a normal state such as pregnancy. Weight changes can be a sign of GI disease, cancer, congestive heart failure with fluid retention, metabolic or endocrine disorders, unhealthy lifestyles, major depressive disorder, and eating disorders. A careful analysis of this symptom provides data that allow the nurse to distinguish between medical and behavioral problems causing the weight change.Weight changes of 2 to 3 lb (1 to 1.4 kg) within 48 hours result from fluid changes. Unexplained weight loss in an adult should raise suspicions of underlying malignancy.

 


 

 

 

 

Indigestion

 

Indigestion—also called dyspepsia or pyrosis—is a frequent abdominal complaint that is usually described as “heartburn.”This burning sensation is usually worse after eating a meal. Acid from the stomach flows into the lower esophagus, causing the burning sensation. GERD has heartburn as its chief symptom, but the epigastric dis- tress occurs more frequently, lasts longer, and has more severe symptoms than indigestion. Heartburn is also a common complaint in both gastric ulcer and duodenal ulcer disease and gallbladder disease. Indigestion that increases when the person is lying flat may indicate a hiatal hernia or GERD. Indigestion associated with belching (eructation) and flatulence suggests cholecystitis

 

Nausea

 

Nausea is caused by stresses on the stomach wall or esophagus. Distension, alterations in peristalsis, negative olfactory stimulation, inner ear problems, or medications can also cause nausea. Many GI medical conditions have nausea as an assessment finding.

 

Vomiting

 

During vomiting, peristalsis is reversed and the esophageal sphincter opens to allow the contents of the stomach to be ejected.The involuntary emptying of stomach contents is caused by irritation of the stomach lining caused by chemicals, trauma, or distension; stimulation of the vomiting center in the brain (medulla); and head injury. Some GI conditions that cause vomiting are intestinal obstruction, peptic ulcer, viral or bacterial infection, and appendicitis.A person with repeated vomiting is always at risk for fluid and electrolyte problems.

 

Past Health History

 

This section of the health history involves asking questions about childhood and adult illnesses, injuries, hospitalizations, allergies, immunizations, and medications that can affect the abdominal structures. Remember to document specific dates in the patient’s record.  

 



 



 

Family History

 

Questioning about diseases in the patient’s family enables you to identify those that the patient may be at risk for because of genetic predisposition.Then you can help the patient plan lifestyle changes that will help prevent those diseases and promote health.  

 


 

Review of Systems

 

A disruption in the systems contained in the abdominal cavity can cause problems in many other areas of the body. The problem in another body system depends on which organ of the abdomen is involved. For example, liver problems may cause malaise, nausea and vomiting, bruising, jaundice, and fluid in the abdomen. This is one reason why taking a careful review of systems (ROS) is so important. Another reason is that the ROS might reveal that the primary health problem does not originate in the abdomen.Instead,you may uncover medical illnesses that have abdominal symptoms. So be sure to keep an open mind about the nature of the patient’s health problem and not conclude that it lies in the GI system simply because he or she has abdominal complaints. Instead, assess each system methodically until you have collected all the data.  

 



 


 

 

Psychosocial Profile

 

The psychosocial profile describes your patient’s lifestyle and habits. How your patient eats, exercises, rests, and copes with the stresses of every day has an impact on the health of the GI system.



 

Anatomical Mapping

 

Anatomical mapping helps pinpoint the location of findings during the abdominal assessment. There are three ways to identify the location of these findings: anatomical landmarks, the four-quadrant method,and the nine regions of the abdomen.

 

Anatomical Landmarks

 

Anatomical structures are used as landmarks to help you describe abdominal findings.The following landmarks are used: xiphoid process of the sternum; costal margin; midline (down the center of the abdomen); umbilicus; anterior-superior iliac spine; inguinal ligament (Poupart’s); and superior margin of the pubic bone (Figs. 17.3 and 17.4).   

 


 

 


Four-Quadrant Method

 

Another way to mark the location of your findings is by the four-quadrant method.To use this method,draw imaginary lines separating the abdomen into four quadrants, with one line at the midline and the other horizontal at the umbilicus.These lines should intersect at the umbilicus. The aorta and the spine are located midline in the abdomen.The uterus and bladder,when enlarged,may be palpable midline in the abdomen (Fig. 17.5).  

 

 

 


 


Nine Regions of the Abdomen

The third way to document the location of your findings is to separate the abdomen into nine regions, similar to a tic-tac-toe grid.The first two lines are vertical at the right and left midclavicular lines to the middle of the inguinal ligaments.The second two lines are horizontal beginning at the lower edge of the costal margin and at the anterior- superior iliac spine of the iliac bones (Fig. 17.6).  

 

 


 

 

Physical Assessment

 

Now that you have completed the subjective part of your examination,proceed to the objective part.The purpose of the physical assessment is to identify normal structures and functions as well as actual and potential health problems. Just as all the organs of the body are interrelated,so are the assessments. Assessment findings in other body areas can also indicate problems with abdominal organs. So your assessment should begin with a general survey and a head-to-toe scan to detect clues that may indicate an abdominal problem.

 

Approach

 

Perform the abdominal examination in a warm, private environment.Have your patient empty her or his bladder before the examination, so that you do not mistake a full bladder for a mass.Ask the patient to lie supine with her or his arms at the sides.Warm both your stethoscope and your hands before proceeding with the examination,and remember to work from the right side of your patient. Once your patient is comfortable, expose the abdomen from the lower thorax to the iliac crests.

 

Other things to remember include:

1.                 Explain what you will be doing during the examination.

2.                 Have adequate lighting so that you can visualize the abdomen without difficulty.

3.                 Observe the patient’s face for signs of discomfort.

4.                 Perform the examination slowly and avoid quick movements.

5.                 Make sure that your fingernails are short, to prevent injuring the patient during palpation.

6.                 Distract the patient with questions or conversation.

 

You will use all four techniques of physical assessment to examine the abdomen. However, the sequence is inspection, auscultation, percussion, and palpation. During an abdominal examination, it is important to auscultate before percussion and palpation because the manipulation that occurs with these techniques may increase the frequency of bowel sounds.  

 

Performing a General Survey

 

Before physically assessing the abdomen, perform a general survey, observing the patient’s overall appearance. Using your inspection skills, note nutritional status, emotional status, body habitus, and any changes that might relate to the abdomen. Begin by taking vital signs, height, and weight. Changes in vital signs may alert you to a serious medical problem.

 

Vital sign changes and related abdominal problems include:

 

1.                 Hypertension: Abdominal aortic aneurysm or dissection, renal infarction, glomerulonephritis, vasculitis, or abdominal pain.

2.                 Orthostatic hypotension: Hypovolemia (fluid or bloodloss).   

3.                 Fever: GI infection,peritonitis, pelvic infection,cholangitis.

4.                 Pulse deficit: Aortic dissection or aneurysm.

5.                 Hypotension/bradycardia: Hypotension may indicate shock associated with ruptured abdominal aortic aneurysm.Vasovagal reaction is caused by bearing down or straining with a bowel movement. The decrease in pulse and BP is a result of decreased blood return to the heart and therefore decreased cardiac output. In addition to taking vital signs, be alert for signs that may indicate underlying abdominal problems. For example, note:

6.                 Facial expression: Is it appropriate? If your patient complains of pain, does her or his nonverbal behavior reflect this? For example, is she or he grimacing?

7.                 Posture: Does your patient assume a particular posture for comfort? For example, is he or she splinting a section of the abdomen, guarding an area of the abdomen, or drawing the knees up to his or her chest? Patients with acute appendicitis often flex their legs, because lying supine often increases the intensity of pain. Does pain seem to increase with movement?

8.                 Weight/nutritional status: Is your patient malnourished and underweight or overweight? Severely thin patients may have an eating disorder. Overweight patients may have underlying cardiovascular or renal disease as a result of fluid retention. Gross abnormalities such as abdominal distension warrant further investigation.

 

Performing a Head-to-Toe Physical Assessment

 

An abdominal assessment reflects many different systems. Therefore, next examine the patient for specific changes that may indicate underlying pathology and might have an impact on the structures of the abdomen.   




 

 

Performing an Abdominal Assessment

 

After you have completed your general survey and headto- toe assessment, focus on the abdomen. Begin with inspection and proceed with auscultation, percussion, and palpation. Next, examine each structure separately. As you proceed with the assessment, try to visualize the underlying structures.

 

 Inspection

 

Inspect the abdomen for size,shape,and symmetry.Look at it from different angles.Check color,surface characteristics, contour, and surface movements. Look for lesions, striae, or scars.

Striae, also known as lineas albicantes or stretch marks, are streaks of light-colored skin that occur after rapid skin stretching.Observe the location of the umbilicus and note any visible veins on the abdomen.Then, have the patient take a deep breath and bear down to assess for bulges that may indicate a hernia or organomegaly. Assess for distension—any unusual stretching of the abdominal wall. If present, determine if it is generalized or in one area. Fluid and gas usually result in generalized, symmetrical distension, whereas anything solid, such as a fetus, mass, tumor, or stool, results in asymmetrical distension. Sometimes distension is difficult to assess, so ask the patient if her or his abdomen looks or feels any different from normal. A concrete way to measure abdominal distention is to measure abdominal girth and compare measurements daily. Measurements should be taken at the umbilicus for consistency. Also inspect the abdomen for any visible aortic pulsations, peristalsis,and respiratory pattern.Slight aortic pulsations and respiratory movements are readily seen in adult patients. Visualization of peristaltic waves may be seen in infants and small children, but this usually indicates a problem if seen in an adult. (See Inspection of the Abdomen.)

 

 Auscultation

 

Begin auscultating the abdomen by placing the warmed diaphragm of the stethoscope gently in one quadrant. Proceed in an organized fashion,listening in several areas in all four quadrants. Use the diaphragm to listen for bowel sounds, which sound like high-pitched gurgles or clicks that last from 1 to several seconds. They are assessed to determine bowel motility and peristalsis.

 Peristalsis is the progressive wavelike movements of the digestive tract that move gastric contents through the tract.There will be 5 to 30 clicks per minute, or bowel sounds occurring every 5 to 15 seconds on an average adult patient. If bowel sounds are hypoactive, listen over the ileocecal valve to the right of the umbilicus.  

 


 


 


 

 

Listen for vascular sounds with the bell of the stethoscope. These sounds include bruits, venous hums, and friction rubs.Apply the bell of the stethoscope lightly on the abdomen. Listen over the aorta in the epigastric region,over the renal, iliac, and femoral arteries. Listen for dilation of a tortuous vessel.Also listen over the epigastric region and liver and around the umbilicus for a venous hum—a soft, low-pitched humming noise with a systolic and diastolic component. Last, listen over the liver and spleen, along the right and left costal margins, for friction rubs.These are grating sounds that increase with inspiration and indicate peritoneal irritation (Fig. 17.7).  


 



 

Percussion

 

Percussion is a technique used to assess the presence of fluid, air, organs, or masses in the abdominal cavity. Indirect or mediate percussion is best for assessing the abdomen.Always ask the patient if he or she has abdominal pain, and percuss painful areas last. Percuss all four quadrants, listening for tympany and dullness (Fig. 17.8)


 Tympany is the most common finding and indicates the presence of gas. Dullness can also be heard when percussing organs, masses, or fluid. Percussion is also valuable for determining organ size and tenderness.The following methods are used for estimating the size of the liver, spleen, and bladder and for assessing kidney tenderness.

 

 

 Assessing Liver Size

 

To help you locate the lower edge of the liver where it is difficult to percuss, use the scratch test: Place your stethoscope over the right upper quadrant (RUQ) above the liver, and with one finger of your other hand, lightly scratch the abdomen starting in the RLQ and moving up toward the liver. When the scratching sound in your stethoscope becomes magnified, you have reached the liver border.

 The liver span test gives you an estimate of the size of the liver at the midclavicular line. To assess the upper border of the liver, start at the right midclavicular line at the third intercostal space over lung tissue and percuss down until you hear resonance change to dullness over the liver (around the fifth to seventh intercostal space). Place a mark where the dullness begins. The upper border of the liver usually begins at the fifth to seventh intercostal space.To determine the lower border of the liver, start at the right midclavicular line at the level of the umbilicus and percuss upward until tympany turns to dullness (usually at the sternal border). Mark this area with a pen. Measure the distance between the two marks—this is the liver span.The normal liver span at the midclavicular line is 6 to 12 cm. If you have a liver span greater than 12 cm at the midclavicular line,you can measure the liver span at the midsternal line.The normal midsternal measurement is 4 to 8 cm

 

. Assessing Spleen Size

 

 Percussion is also helpful in estimating the size of the spleen. Three methods are used. The first method is to percuss from the left midclavicular line along the costal margin to the left midaxillary line. If you hear tympany, splenomegaly is unlikely. Dullness in the area of the anterior axillary line to the midaxillary line is a sign of spleen enlargement. A second method of assessing splenomegaly is to percuss at the lowest intercostal space at the left anterior axillary line (Fig. 17.9).


 Ask the patient to take a deep breath and percuss again.Tympany is normal, but with splenomegaly, the tympany turns into dullness on inspiration. The third method is to percuss from the third to the fourth intercostal space slightly posterior to the left midaxillary line, and percuss downward until dullness is heard instead of tympany or resonance. Dullness of the normal spleen will be noted around the ninth to the eleventh rib.

 

 

Assessing Bladder Size

 

To percuss the bladder for distension, begin at the symphysis pubis and percuss upward to the umbilicus, noting any dullness. Normally, an empty bladder does not rise above the symphysis pubis.

 

Assessing Kidney Tenderness

 

Fist or blunt percussion can be used to assess the kidneys for tenderness. Assess the kidneys at the costovertebral angle (CVA). Posteriorly, identify the CVA where the end of the rib cage meets the spine. Place the palm of your nondominant hand over the CVA, and strike that hand with the fist of your other hand.Repeat on the other side. Tenderness upon blunt percussion at the costovertebral angle is positive CVA tenderness.

 




 

Palpation

 

You will use both light and deep palpation to assess the abdomen. Begin with light palpation to put your patient at ease. Light palpation is useful in assessing surface characteristics and identifying areas of tenderness. If the patient has identified an area of pain, examine that area last. Otherwise, the patient may tense her or his muscles, affecting the accuracy of your assessment.

 Perform light palpation in all four quadrants, using your fingertips. Press down 1 to 2 cm in a rotating motion, then lift your fingers and assess the next location.Palpate as much of the abdomen as possible. Observe for nonverbal signs of pain,such as grimacing or guarding.No tenderness should be noted.

 To palpate for muscle guarding, perform light palpation over the rectus muscles of the abdomen.The normal response is easy palpation of the muscle. If guarding is present, determine if it is voluntary or involuntary by placing a pillow under the patient’s knees and asking him or her to take several slow, deep breaths. Palpate the rectus abdominis muscles on expiration.The patient cannot voluntarily tense this muscle during expiration, so if involuntary guarding is present, you will feel a boardlike rigidity that indicates peritonitis.

 Deep palpation is used to assess organs, masses, and tenderness. It can be done using a manual or bimanual technique.To perform single-handed deep palpation, use the distal portion of your fingertips and depress 4 to 6 cm in a dipping motion in all four quadrants, assessing for masses or areas of tenderness.To perform bimanual deep palpation, place your nondominant hand on your dominant hand, then depress your hands 4 to 6 cm. Bimanual palpation is useful when palpating a large abdomen. Tenderness may be noted in a normal adult near the xiphoid or over the cecum or sigmoid colon. If you find a mass, note its location, size, shape, consistency (soft, firm, hard), tenderness, pulsation, mobility, and movement with respiration.  


 

Assessing Abdominal Structures

 

While assessing the abdomen, you will need to examine specific abdominal structures. The following section describes the examination of these structures and explains the difference between normal and abnormal findings.

 

 Abdominal Aorta

 

To palpate the abdominal aorta, place your fingers in the epigastric portion of the abdomen and slightly toward the patient’s left midclavicular line.Palpate for aortic pulsations. You can also assess the width of the aorta by placing one hand on each side of the aorta.

 Liver

 

 To palpate the liver,place your right hand at the patient’s right midclavicular line under the costal margin. Place your left hand posteriorly on the patient’s right eleventh to twelfth rib and press upward to elevate the liver toward the abdominal wall. Have the patient inhale and exhale deeply while you press your right hand gently but deeply in and up during inspiration. The hooking technique is another way to palpate the liver.Place your hands over the right costal margin and hook your fingers over the edge. Have the patient take a deep breath and feel for the liver’s edge as it drops down on inspiration, then rises up over your fingers during expiration. (See Palpating the Liver.)

 

 Spleen

 

To palpate the spleen, stand on the patient’s right side, place your left hand under the left CVA, and pull upward to move the spleen anteriorly. Place your right hand under the left anterior costal margin and have the patient take a deep breath in and out. During exhalation, press inward along the left costal margin and try to palpate the spleen. (See Palpating the Spleen.)

 

Kidneys

 

To assess the left kidney, stand on the patient’s right side and place your left hand in the left CVA of her or his back. Place your right hand at the left anterior costal margin. Have the patient take a deep breath, then press your hands together to “capture” the kidney. As the patient exhales, lift your left hand and palpate the kidney with your right hand. To assess the right kidney, remain on the patient’s right side and place your right hand on the right posterior CVA and your left hand on the patient’s right anterior costal margin.When the patient exhales, palpate the kidney. (SeePalpating the Kidneys.)    

 


 


 



 

Bladder

Palpate the bladder in the hypogastric area up to the umbilicus, using deep palpation. (See Palpating the Bladder.)

 

 Inguinal Lymph Nodes

 

Using the pads of your fingers, palpate just below the inguinal ligament for the superficial superior (also called the horizontal) inguinal lymph nodes and along the inner aspect of upper thigh for the superficial inferior (also called the vertical) inguinal lymph nodes.

 If nodes are palpable, note size, shape, mobility, consistency, and tenderness (See Palpating Inguinal Lymph Nodes.).