ABDOMEN
PROCEDURE
RATIONALE/ NORMAL AND DEVAITIONS
Introduce oneself and verify client via two-patient
identifier.
Ensures correct client.
Explain to the client what you are going to do, why
it is necessary, & how he/she can participate.
Encourages cooperation.
Discuss how results will be used in the planning
Perform hand hygiene.
Reduces transmission of microorganisms.
Provide client privacy
Demonstrates respect for client’s dignity.
Inquire if there are any abdominal problems or
pain.
For documenting health history.
Assist client to supine position, arms at the sides.
Place small pillows beneath knees and head.
Reduces tension in the abdominal muscles.
Expose client’s abdomen only from chest line to
pubic area
Inspect skin integrity
Inspect abdomen for contour
Ask client to take deep breath and hold it
Assess symmetry of contour while standing at foot
of bed
Avoid chilling and shivering which can tense
abdominal muscles.
Check for abnormalities.

Normal: Unblemished skin, uniform color,
silver-white striae (stretch marks/ surgical
scars)

Deviations:
Rash,
lesions,
tense,
glistening(may indicate ascites or edema),
Purple striae ( Cushing’s disease- releases too
much ACTH that leads to hyperpigmentation
OR could be caused by rapid weight gaina nd
loss)
Check for abnormalities.

Normal: Flat, rounded(convex) or scaphoid
(concave)

Deviation: Distended(bloated-swollen sue to
pressure inside)
Makes enlarged liver or spleen visible.

Normal: No enlargement

Deviation: There is enlargement
Check for abnormalities.

Normal:Symmetric

Abnormal:Asymmetric
If distention is present, measure with abdominal
girth by placing tape around abdomen at level of
the umbilicus, If girth will be measured repeatedly,
use skin marking pen
Maintain consistency for future measurements
Observe location of umbilicus
Check for abnormalities.
Observe abdominal movements associated with:
Respiration:

Normal: vertical level corresponding to the
junction between the L3 and L4 vertebrae

Abnormal: other locations
Check for abnormalities.

Normal: Symmetric movements

Deviation: Limited
pain/disease

Normal: Visible peristalsis in very lean people

Deviations: Visible peristalsis in non clean
clients

Normal: Aortic pulsations in thin people at
epigastric area

Deviations:Marked aortic pulsations
Peristalsis:
or Aortic pulsations:
Warm hands and chest piece
movement
due
to
Prevent vasoconstriction
Auscultate abdomen for:
A. Bowel sounds( diaphragm)


Ask when the client ate
Place diapghram in all 4 quadrants and listen
for active bowel sounds
Intestinal sounds are high pitched and is best
accentuated by the diaphragm.

After
eating,
bowel
sounds
may
increase.After 4-7 hours, sounds may be
heard continuously on the right lower
quadrant due to digestive contents being
emptied from the small intestine through the
ileocecal valve and into the large intestine.

irregular gurgling noises (lasts for 5-20
seconds & less than a second to several
seconds for a single sound )
B. Vascular sounds (Bell)

Use bell over the aorta, renal arteries, iliac
arteries, and femoral arteries.

Listen for bruits(abnormal mumurs)
C. Peritoneal friction rubs(Bell)

Definition: rough, grating sounds like 2 pieces
of leather rubbed together. It is caused by
inflammation, infection, or abnormal
growths.

Normal: Absence of bruits

Deviations: Bruit in aortic area,renal, or iliac
arteries

Normal: No peritoneal friction rubs

Deviation: Presence of friction rub