NURS 307
Health Assessment of Diverse Populations
Rebecca Benfield CNM, PhD
Chapter 22
Abdomen
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Internal Anatomy
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Inside abdominal cavity, all internal organs are called viscera.
Peritoneum lines abdominal wall (parietal) and covers surface
(visceral) of most organs.
Solid viscera maintain characteristic shape.
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Shape of hollow viscera depends on content.
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Liver, pancreas, spleen, adrenal glands, kidneys, ovaries, and uterus
Stomach, gallbladder, small intestine, colon, and bladder
Divided into 4 quadrants
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Right and left and upper and lower
Midline organs—aorta, uterus if enlarged and bladder if distended
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Abdominal Cavity
Know the placement of these organs
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Anatomic Locations of Organs in the
Right Upper Quadrant
 Right upper quadrant (RUQ)
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Liver
Gallbladder
Duodenum
Head of pancreas
Right kidney and adrenal gland
Hepatic flexure of colon
Part of ascending and transverse colon
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Anatomic Locations of Organs in Left
Upper Quadrant
 Left upper quadrant (LUQ)
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Stomach
Spleen
Left lobe of liver
Body of pancreas
Left kidney and adrenal gland
Splenic flexure of colon
Part of transverse and descending colon
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Anatomic Locations of Organs in the
Lower Quadrants
 Right lower quadrant (RLQ)
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Cecum
Appendix
Right ovary and tube
Right ureter
Right spermatic cord
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Part of descending colon
Sigmoid colon
Left ovary and tube
Left ureter
Left spermatic cord
 Left lower quadrant (LLQ)
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Quadrants
Know both diagrams
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Culture and Genetics
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Lactose intolerance
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Lactase is a digestive enzyme necessary for absorption of
carbohydrate lactose (milk sugar).
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Ethnic variation seen
Estimated incidence of lactose intolerance is
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These people are lactose intolerant and have abdominal pain,
bloating, and flatulence when milk products are consumed.
20% to 30% of whites, 70% of Mexican Americans, and 80% of
blacks and 100% American Indians.
Celiac disease
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Autoimmune disorder
Intolerant of gluten roughly 1% or 4% with a diagnosis- most
affected Punjab region of India.
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Subjective Data
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Appetite
Dysphagia
Food intolerance
Abdominal pain
Nausea and vomiting
Bowel habits
Past abdominal history
Medications
Nutritional assessment
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Subjective Data Questions
 Appetite: Ask about
 changes in appetite—time period and amount.
 changes in weight—loss or gain (amount) and time period.
 Dysphagia: Ask about
 any difficulty in swallowing.
 onset and associated symptoms.
 Food intolerance: Ask about
 type of food reaction that occurs.
 use of Rx or OTC medication—amount and frequency.
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Subjective Data Questions
 Pain: Ask about
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onset, duration, location and severity.
characteristics (quality and pattern) and associated symptoms.
with regard to eating, pain getting worse or better.
association with any other clinical symptoms.
alleviating factors and aggravating factors.
treatment methods: Rx and OTC.
 Nausea and Vomiting: Ask about
 onset, frequency, type and amount.
 associated symptoms and/or triggers.
 recent foods eaten and/or travel habits.
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Subjective Data Questions
 Bowel habits: Ask about
 frequency, color, consistency, diarrhea or constipation.
 any recent changes.
 laxative use—type, amount and frequency.
 Past abdominal history: Ask about
 GI disease/pathology.
 GI diagnostic procedures.
 GI surgeries and clinical response.
 Medications: Ask about
 Rx and OTC.
 alcohol—type, amount, and frequency.
 smoking history.
 Nutritional assessment: Ask about
 dietary history.
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Developmental Competence:
Aging Adult
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Abdominal wall musculature relaxes.
Changes of the GI system occur with aging, but most do not
significantly affect function as long as no disease is present.
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Salivation decreases, leading to a dry mouth and decreased sense
of taste.
Esophageal emptying and gastric acid secretion are delayed.
Incidence of gallstones increases with age.
Although liver size decreases, most liver functions remain
normal; however, drug metabolism is impaired.
Aging adults frequently report constipation.
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Additional History for Aging Adults
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Ask about
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access to groceries and food preparation.
shared meals or eats alone.
24 hour dietary recall.
swallowing or feeding difficulties.
activities done following mealtimes.
bowel health—frequency, constipation, fiber in your diet, use of
laxatives.
medications—Rx and OTC.
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Common Causes of Constipation
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Found in the older adult
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Decreased physical activity
Inadequate intake of water
Low-fiber diet
Side effects of medications
Irritable bowel syndrome
Bowel obstruction
Hypothyroidism
Inadequate toilet facilities, that is, difficulty ambulating to toilet
may cause a person to deliberately retain stool until it becomes
hard and difficult to pass
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Summary Checklist: Abdomen
Examination
 Inspection
 Contour, symmetry, umbilicus, skin, pulsation or movement,
hair distribution, and demeanor
 Auscultation
 Bowel sounds; note any vascular sounds
 Palpation
 Light and deep palpation in all four quadrants, and palpate for
liver and spleen
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Objective Data
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Preparation
Adequate lighting
 Expose abdomen so that it is fully visible; drape genitalia and female
breasts.
 Position for comfort to enhance abdominal wall relaxation (knees bent,
arms at sides).
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Empty bladder prior to examination with specimen saved if needed.
Warm stethoscope and examine areas identified as painful last so as to
prevent guarding.
Auscultate prior to palpation
Use distraction to keep patient relaxed and facilitate muscle
relaxation.
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Inspection of the Abdomen (1 of 2)
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Contour
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Symmetry
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Abdomen should be symmetric bilaterally.
Umbilicus
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Determine profile from rib margin to pubic bone; contour describes
nutritional state and normally ranges from flat to rounded.
Normally it is midline and inverted, with no sign of discoloration,
inflammation, or hernia.
Skin
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Surface smooth and even, with homogeneous color; assess skin
turgor
Inspect for pigment change and presence of lesions or scars.
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Contour
Know these abdominal
descriptors
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Inspection of the Abdomen (2 of 2)
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Pulsation or movement
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Hair distribution
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Normally you may see pulsations from aorta beneath skin in epigastric
area, particularly in thin persons with good muscle wall relaxation.
Pattern of pubic hair growth normally has diamond shape in adult males
and an inverted triangle shape in adult females.
Demeanor
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A comfortable person is relaxed quietly on examining table and has a
benign facial expression and slow, even respirations.
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Auscultation of Bowel and Vascular
Sounds
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This is done because percussion and palpation can increase
peristalsis, which would give a false interpretation of bowel
sounds.
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Use diaphragm endpiece because bowel sounds are relatively high
pitched.
Hold stethoscope lightly against skin; pushing too hard may
stimulate more bowel sounds.
Begin in RLQ at ileocecal valve area because bowel sounds are
normally always present here.
Auscultate vascular sounds for bruits using a firmer pressure over
the aorta (see photo 22.12 page 542) normally no sound will be
present. Note aortic width normally 2.5 cm- 4.cm. (pg 542)
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Bowel Sounds
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Note character and frequency of bowel sounds.
Bowel sounds originate from movement of air and fluid through small
intestine.
Bowel sounds are high pitched, gurgling, cascading sounds, occurring
irregularly anywhere from 5 to 30 times per minute
Abnormal bowel sounds:
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Hypoactive—decreased, can follow abdominal surgery or with
inflammation
Hyperactive—loud, high-pitched signal increased motility
Borborygmus is the sound of hyper peristalsis associated with
mechanical bowel obstruction, gastroenteritis, brisk diarrhea.
Perfectly “silent abdomen” is uncommon; you must listen for 5 minutes
by your watch before deciding bowel sounds are completely absent.
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Vascular Sounds
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As you listen to abdomen, note the presence of any vascular sounds or
bruits. Bruits are "swishing" sounds heard over major arteries during
systole or, less commonly, systole and diastole. The area over the
aorta, both renal arteries. and the iliac arteries should be examined
carefully for bruits.
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Small percentage of healthy people may have a bruit.
Using firmer pressure, check over aorta, renal arteries, iliac, and
femoral arteries, especially in people with hypertension.
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Light and Deep Palpation
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With either technique, note location, size, consistency, and mobility of
any palpable organs and presence of any abnormal enlargement,
tenderness, or masses
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Inexperienced examiners complain that abdomen “all feels same,” as if
they are pushing their hand into a soft sofa cushion.
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Making sense of what you are feeling is more difficult than it looks.
Helps to memorize anatomy and visualize what is under each quadrant as
you palpate
Also remember that some structures are normally palpable.
Mild tenderness normally present when palpating sigmoid colon
Any other tenderness should be investigated.
If you identify a mass, first distinguish it from a normally palpable
structure or an enlarged organ.
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Palpate Surface and Deep Areas
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Perform palpation.
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Judge size, location, and consistency of certain organs
and screen for an abnormal mass or tenderness.
Because most people are naturally inclined to protect
abdomen, you need to use additional measures to
enhance complete muscle relaxation.
Begin with light palpation no greater than 1 cm in
depth then proceed to deep palpation.
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Normally Palpable Structures
Know this information
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Identification of a Mass
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If you identify a mass, then note the following:
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Location
Size
Shape
Consistency: soft, firm, hard
Surface: smooth, nodular
Mobility, including movement with respirations
Pulsatility
Tenderness
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Palpation of Spleen and Liver
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Normally spleen is not palpable and must be enlarged three
times its normal size to be felt.
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With Deep palpation you might feel the lower edge of the liver.
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Palpation of Spleen (2 of 2)
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Enlargement seen with:
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Mononucleosis, leukemia and lymphomas, portal HTN and HIV
infection
Normally spleen is not palpable and must be enlarged three times
its normal size to be felt.
An alternative position is to roll a person onto his or her right side
to displace spleen more forward and downward.
If palpable, do not continue to palpate as it is friable (tissue that
tears, sloughs, and bleeds more easily when touched) and can
rupture.
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Palpation of the Aorta
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Using your opposing thumb and fingers, palpate
aortic pulsation in upper abdomen slightly to left
of midline.
Normally it is 2.5 to 4 cm wide in adult and
pulsates in an anterior direction.
Widened in the presence of abdominal aortic
aneurysm (anormal bulge or ballooning of blood
vessel wall)
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Developmental Competence:
The Aging Adult
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On inspection, you may note increased deposits of subcutaneous fat
on abdomen and hips because it is redistributed away from
extremities.
Abdominal musculature is thinner and has less tone than that of
younger adult, so in absence of obesity you may note peristalsis.
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Because of thinner, softer abdominal wall, organs may be easier to
palpate, in the absence of obesity.
Liver and kidneys are easier to palpate.
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With distended lungs and depressed diaphragm, liver can be palpated
lower, descending 1 to 2 cm below costal margin with inhalation.
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Costovertebral Angle Tenderness
CVAT
 Positive finding of pain indicates inflammation of the kidney.
 Indirect fist percussion causes tissues to vibrate instead of
producing a sound.
 To assess kidney, place one hand over 12th rib at costovertebral
angle on back.
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Thump that hand with ulnar edge of your other fist.
 A person normally feels thud but no pain.
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Its usual sequence in complete examination is with thoracic
assessment, when the person is sitting up and you are standing
behind.
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Common Sites of Referred
Abdominal Pain
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Liver—RUQ
Esophagus—behind lower sternum
Ulcer—shoulder
Gallbladder—RUQ
Appendix—RLQ
Pancreas—Midscapular
Kidney—flank pain
Small intestine—diffuse
Colon—colicky pain and bloating
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Urine
 Normal urine is clear and slightly acidic with a pH range of
4.5 to 8.0
 Specific gravity measures the concentration of urine from
dilute at 1.003 to 1.030
 There is little or no protein, no glucose and fewer than 5
red blood cells or white blood cells per high-powered field
in the microscope.
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Cloudiness suggests presence of WBS, bacteria and casts
Certain drugs or foods can change the urine color
Proteinuria indicates glomerular disease in the nephron
Glycosuria suggest hyperglycemia with diabetes
Increased WBC and RBC occur with UTI
Review pg.697 and abnormal findings in text box
Daily Fluid Intake
 So how much fluid does the average, healthy adult living
in a temperate climate need? The National Academies of
Sciences, Engineering, and Medicine determined that an
adequate daily fluid intake is:
 About 15.5 cups (3.7 liters) of fluids for men
 About 11.5 cups (2.7 liters) of fluids a day for women
 These recommendations cover fluids from water, other
beverages and food. About 20 percent of daily fluid intake
usually comes from food.
 Water 8-8oz. glasses
 Mayo Clinic
Know Colors on this Chart
Bowel Movement and Stool Characteristics
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Usual Elimination pattern (number of stools daily, time of day, routine)
Color
Shape
Consistency (hard, soft)
Changes???
Appetite and nutritional intake (fruits, veggies, roughage)
Fluid intake
Medications
Exercise
Living arrangements
Mobility and dexterity
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Note:
Abdominal Distention
Feces palpable in Descending colon
Pain
Abnormal Bowel sounds (hyper, hypo)
Consider constipation, impaction, diarrhea, incontinence, flatulence, hemorrhoids
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