Abdomen:
Disorders
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
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
. 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
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
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.).