ADVENTIST MEDICAL CENTER COLLEGE
San Miguel, Iligan City
SCHOOL OF NURSING
HEALTH ASSESSMENT
Related Learning Experience (Skills Lab)
Second Semester, AY 2022 – 2023
ASSESSMENT OF ABDOMEN RUBRIC
Name _______________________________________________________________________________________ Section _________ Date __________________ Score _______
I. COLLECTING SUBJECTIVE DATA: THE NURSING HEALTH HISTORY
CRITERIA AND PROCEDURE
EXCELLENT
VERY
SATISFACTORY
4
SATISFACTORY
2
3
Preliminaries and Client Preparation
Demonstrated
Demonstrated 9
Demonstrated 8
all (10)
preliminary and
preliminary and
1. Student must wear the required and appropriate attire as well as observe proper grooming prior to the
preliminary and client preparation
client
examination.
client
activities
preparation
2. Prepare equipment (examination gown and drape, small pillow or rolled blanket, stethoscope, light
preparation
activities
source, skin marker, metric ruler, marking pen, gloves when necessary, assessment form, ballpen,
activities
clipboard).
POOR
1
Demonstrated 7 or
less of the
preliminary and
client preparation
activities
3. Demonstrate courtesy, introduce self, and verify client’s identity. Explain to the client that after the
nursing health history, you will proceed to the physical assessment or physical examination. Provide
continuous explanation as you perform the various assessment techniques.
4. Do hand hygiene and observe other infection control procedures.
5. Provide privacy.
6. Position the client to be seated comfortably.
7. Provide a quiet environment.
8. Be sure that the room is having a comfortable temperature.
9. Ensure that during the interview, there are no interruptions and distractions.
10. Ask questions in a straightforward manner, be sensitive, and avoid being judgmental. Encourage
client to ask questions also and inform you of any discomfort or fatigue experienced during the
examination.
History of Present Health Concern
Abdominal Pain
Are you experiencing abdominal pain? If the client answers yes, use COLDSPA to further explore this
symptom:
Character: Describe the pain (dull, aching, burning, gnawing, pressure, colicky, sharp,
knife-like, stabbing, throbbing, variable).
Onset: When did (does) the pain begin?
EXCELLENT
Demonstrated
complete and
comprehensive
interview on
history of
present health
concern
VERY
SATISFACTORY
Missed one to two
assessment
interview on
history of present
health concern
SATISFACTORY
Missed three to
four assessment
interview on
history of
present health
concern
POOR
Missed five or more
assessment
interview on
history of present
health concern
1
SCORE
Location: Point to the area where you have this pain. Does it radiate or spread to other areas?
Where is the pain located? Does it move or has it changed from the original location?
Duration: How long does the pain last?
Severity: How bad is the pain (severity) on a scale of 1 – 10, with 10 being the worst?
Pattern: When does the pain occur (timing and relation to particular events such as eating,
exercise, bedtime? What seems to bring on the pain (precipitating factors), or make it better
(alleviating factors)?
Associated factors/How it Affects the client: Is the pain associated with any other symptoms
such as nausea, vomiting, diarrhea, constipation, gas, fever, weight loss, fatigue, or yellowing of the eyes
or skin?
Indigestion
Do you experience indigestion?
Character: Describe how this feels.
Onset: When did you first experience this?
Location: Point to where you usually feel indigestion.
Duration: How long does the indigestion last? How often does it recur?
Severity: Describe the severity of this feeling on a scale of 1- 10 (10 being the worst). Does the indigestion cause
you to quit any of your activities of daily living if it occurs? What activities can you not do when you have
indigestion?
Pattern: Does anything in particular seem to cause or aggravate the indigestion? Have you noticed that this
sensation occurs after you eat certain foods?
Associated factors: Do you have any other symptoms with indigestion, such as nausea, vomiting, diarrhea, or
constipation?
Nausea and Vomiting
Do you experience nausea or vomiting? Describe it. Is it triggered by any particular activities, events, or other
factors (smells, eating certain foods, riding in a car, boat, or plane, or strenuous physical exercise)?
Appetite
Have you noticed an increase or decrease in your appetite? Has this change affected how much you eat or
your normal weight? When did it begin? Does it come and go? What other illnesses or life events were
you experiencing when this occurred? Is there anything that aggravates or improves this appetite
change?
Bowel Elimination
1. Describe your stools (how many a day and consistency and color). Have you experienced a change in bowel
elimination patterns?
2. Do you have constipation? Describe. Do you have constipation? Describe. Do you have any accompanying
symptoms?
3. Have you experienced diarrhea? Describe. Do you have any associated symptoms?
4. Have you experienced any yellowing of your skin or whites of your eyes, itchy skin, dark urine (yellow brown or
tea-colored), or clay-colored stools?
2
Personal Health History and Family History
1.
Have you ever had any of the following gastrointestinal disorders: ulcers, GERD, inflammatory or
obstructive bowel disease, pancreatitis, gallbladder or liver disease, diverticulosis, or appendicitis?
2.
Have you had any urinary tract disease such as infections, kidney disease or nephritis, or kidney
stones?
3.
Have you ever had viral hepatitis (A, B, C)? Have you ever been exposed to viral hepatitis?
4.
Have you ever had abdominal surgery or trauma to the abdomen?
5.
What prescription or over the counter (OTC) medications do you take? Is there a history of any of
the following diseases or disorders in your family: colon, stomach, pancreatic, liver, kidney, or
bladder cancer; liver disease,; gallbladder disease; kidney disease?
6.
Has anyone in your family had any type of gastrointestinal cancer or other GI disorders?
EXCELLENT
Demonstrated
complete and
comprehensive
interview on
personal health
history and
family history
VERY
SATISFACTORY
Missed one
assessment
interview on
personal health
history and family
history
SATISFACTORY
Missed two
assessment
interview on
personal health
history and
family history
POOR
Missed three or
more of the
assessment
interview on
personal health
history and family
history
Lifestyle and Health Practices
1. Do you drink alcohol? How much? How often?
2. What types of foods and how much food do you typically consume each day? How much noncaffeinated fluid do you consume each day?
3. How much caffeine do you think you consume each day (e.g., in tea, coffee, chocolate, and soft
drinks)?
4. How much and how often do you exercise? Describe your activities during the day.
5. What kind of stress do you have in your life? How does it affect your eating or elimination habits?
6. If you have a gastrointestinal disorder, how does it affect your lifestyle and how you feel about
yourself?
EXCELLENT
Demonstrated
complete (7)
and
comprehensive
interview on
lifestyle and
health practices
VERY
SATISFACTORY
SATISFACTORY
POOR
Missed three or
more assessment
interview on
lifestyle and health
practices
EXCELLENT
Performed all
(12) steps of the
preliminaries
and client
preparation
VERY
SATISFACTORY
Missed one to two
steps of the
preliminaries and
client preparation
Missed one
assessment
interview on
lifestyle and health
practices
Missed two
assessment
interview on
lifestyle and
health practices
II. COLLECTING OBJECTIVE DATA: PHYSICAL EXAMINATION
Preliminaries and Client Preparation
1. Gather equipment examination gown and drape, small pillow or rolled blanket, stethoscope, light source, skin
marker, metric ruler, marking pen, gloves when necessary, assessment form, ballpen, clipboard).
2. Ask client to empty bladder before examination
3. Adjust bed level and approach client from right side
4. Ask the client to remove clothes and put on gown
5. Assist to supine position with arms folded across chest or resting at sides
6. Use pillow under head for comfort; slightly flex client’s legs by placing pillow or rolled blanket under client’s
knees to relax abdominal muscles
7. Drape client (abdomen is visible from lower rib cage to pubic area)
8. Instruct client to breathe through mouth and take slow deep breaths
9. Before touching abdomen, ask about painful and tender areas which should be assessed at end of examination
10. Warm your hands
11. For ticklishness: use hands-on technique by placing client’s hand under your own for a few moments at
beginning of palpation
12. Listen and observe for verbal and nonverbal cues
SATISFACTORY
Missed three to
four steps of
the
preliminaries
and client
preparation
POOR
Missed five or more
steps of the
preliminaries and
client preparation
3
Inspection
1. Inspect the skin noting color, vascularity, striae (stretch marks), scars (measure using a centimetre ruler; note
location, shape, length, and any specific characteristics), lesions, and rashes (wear gloves to inspect lesions and
rashes).
2. Inspect the umbilicus noting color, location, and contour from various angles. Ask patient to raise head off the
bed , note any bulges (hernias)
3. Inspect the contour of the abdomen from various angles. Measure abdominal girth.
4. Inspect the symmetry of abdomen (with client in supine position). To assess for herniation or diastasis recti or
to differentiate a mass within the abdominal wall from one below it, ask the client to raise the head.
5. Inspect the abdominal movement, noting the respiratory movement, aortic pulsations, and peristaltic waves.
EXCELLENT
Performed
complete and
comprehensive
inspection of
the abdomen
VERY
SATISFACTORY
Missed one to two
steps in the
inspection of the
abdomen
SATISFACTORY
Missed three to
four steps in
the inspection
of the abdomen
POOR
Missed all (5) steps
in the inspection of
the abdomen
Auscultation
Auscultate using the diaphragm (warm it first) of the stethoscope for bowel sounds up to 5 minutes in each
quadrant beginning in the RLQ and proceed clockwise noting intensity, pitch, and frequency.
EXCELLENT
Performed
complete and
comprehensive
auscultation of
the abdomen
VERY
SATISFACTORY
Missed one step in
the auscultation of
the abdomen
SATISFACTORY
Missed two
steps in the
auscultation of
the abdomen
POOR
Missed three or
more steps in the
auscultation of the
ABDOMEN
EXCELLENT
VERY
SATISFACTORY
SATISFACTORY
POOR
Missed three to
four steps in
the percussion
of the abdomen
Missed all (5) steps
in the percussion of
the abdomen
Auscultate for vascular sounds:
• Bruits (low-pitched, murmur-like sound)
If indicated listen with the bell of the stethoscope over the:
> abdomen at the midline of the epigastric area,
> renal arteries above the umbilicus to the right and left of the midline in the upper
quadrants.
> iliac arteries below the umbilicus to the right and left of the midline in the lower
quadrants.
• Venous hums (if indicated listen using the bell of the stethoscope) over the liver in the RUQ, epigastric, and
umbilical areas.
• Friction rubs (if indicated listen using the diaphragm of the stethoscope) over inflamed organs or tumors (e.g.,
over liver, spleen)
Percussion
1. Percuss all four quadrants for tones using indirect or mediate percussion with tender
areas last. Percussion tones will vary from dull to tympanic, with tympany dominating over
the hollow organs, which include the stomach, intestines, bladder, aorta, and gallbladder. Dull percussion will
be heard over the liver, spleen, pancreas, kidneys, and uterus. Percuss from areas of tympany to dullness to locate
borders of these solid organs.
2. Percuss the liver for span, starting below the umbilicus at client’s right midclavicular line (MCL), and percuss
upward until you hear dullness, mark this point. Measure the distance between the upper and lower marks to
obtain a liver span.
3. Percuss the spleen.
Position the patient on right side, percuss down the midaxillary line from an area of resonance over the lung to
dullness over the spleen.
4. Perform blunt percussion on the liver and the kidneys.
Place non-dominant hand over kidney. Make a fist with dominant hand and strike non-dominant hand. Note any
tenderness.
Performed
complete and
comprehensive
percussion of
the abdomen
Missed one to two
steps in the
percussion of the
abdomen
4
5. If indicated percuss for bladder
Dullness at the midline above the symphysis pubis (with full bladder).
Palpation
1. Perform light palpation about ½ inch, noting tenderness, or guarding in all quadrants.
2. Perform deep palpation, noting tenderness, or masses in all quadrants.
Single hand technique. Use dominant hand and palpate more than 1/2 inch in each quadrant.
Bimanual hand technique. Place dominant hand on abdomen, place non- dominant hand on top, and palpate
greater than ½ inch in each quadrant.
3. Palpate the umbilicus and surrounding areas for swellings, bulges, or masses.
4. Palpate in the epigastric region (using thumb and first finger or use two hands to palpate deeply) at the midline
for the abdominal aortic pulsation.
5. Palpate the liver noting the consistency and tenderness.
Stand at the right side of the patient. Place left hand under the patient’s back at the costovertebral angle (CVA)
and place right hand along the costal margin at the right midclavicular line. Have patient take a deep breath as you
press your right hand in and up, while at the same time with your left hand press upward to elevate the liver.
6. Palpate the spleen noting the consistency and tenderness.
Stand at the right side of the patient. Place left hand under the patient’s back at the left costovertebral angle
(CVA) and place left hand along the right costal margin. Have patient take a deep breath while you press inward
along the costal margin.
7. Palpate the kidneys for consistency and tenderness
EXCELLENT
Performed
complete and
comprehensive
palpation of the
abdomen and
internal organs
VERY
SATISFACTORY
Missed one to two
steps in the
palpation of the
abdomen and
internal organs
SATISFACTORY
POOR
Missed three to
four steps in
the palpation of
the abdomen
and internal
organs
Missed five steps or
more in the
palpation of the
abdomen and
internal organs
SATISFACTORY
POOR
Missed three to
four steps in
the tests for
ascites,
appendicitis,
and
cholecystitis
Missed five steps or
more in the tests
for ascites,
appendicitis, and
cholecystitis
For the right kidney. Stand at the right side of the patient. Place your right hand under the patient’s back at the
costovertebral angle (CVA) and your left hand below the costal margin. Capture the kidney by pressing hands
together as the patient’s breathes.
For the left kidney. Stand at the right side, placing the left hand under the patient’s at the left CVA and the right
hand below the costal margin.
Palpate the urinary bladder for consistency and tenderness
Palpate above the symphysis pubis at the midline.
EXCELLENT
Tests for Ascites
Perform the test for shifting dullness.
Have patient lie supine and percuss the abdomen for dullness and tympany.
Perform the fluid wave test.
Have the patient place her/ his hand vertically in the middle of her/ his abdomen. Place your hands on each side of
the patient’s abdomen and tap one side while palpating the other side. If ascites is present, the tap will cause a
fluid wave through the abdomen and you will feel the fluid on the other hand.
Performed
complete and
comprehensive
tests for ascites,
appendicitis,
and
cholecystitis
VERY
SATISFACTORY
Missed one to two
steps in the tests
for ascites,
appendicitis, and
cholecystitis
5
Tests for appendicitis/ peritoneal irritation
Rebound tenderness (McBurney’s sign)
Place your hand perpendicular (90 degrees) to the abdomen halfway between the umbilicus and the anterior iliac
crest (McBurney point), press firmly and slowly and release quickly. (perform only if patient complain of
abdominal pain). Note for tenderness.
Rovsing sign
Place your hand on the LLQ of the patient’s abdomen and press deeply for 5 seconds and quickly release pressure
and note for tenderness.
Iliopsoas Muscle Test
As patient lies supine, place your hand over her/ his lower right thigh. Ask the patient to raise her/ his right leg by
flexing the hip while you push downward. Note for pain in the RLQ.
Obturator Muscle Test
Patient lies supine and flexes right leg at hip and knee. Place one hand just above patient’s knee and other hand at
the ankle, and rotate leg internally and externally. Note for pain in the RLQ.
Cutaneous Hypersensitivity test.
Grasp a fold of skin or touch the abdominal surface with an open safety pin to assess for pain. Assess entire
abdomen surface. Note for pain or exaggerated sensation in the RLQ.
Perform the test for cholecystitis ( Murphy sign).
Stand at the right side of the patient, and palpate at the right midclavicular line under the costal angle as the
patient takes a deep breath. Note for tenderness.
Post-Examination Activities
1. Show appreciation to your client for cooperating.
3. Perform hand hygiene.
4. Discard disposable materials properly.
5. Disinfect materials that will still be reused prior to storing them.
6. Document findings in the client record supplemented by narrative notes.
.
IV. QUALITY OF PERFORMANCE
- Spontaneity (spontaneous in communication)
- Articulation: diction and grammar
- Mastery of the subject matter
- Video: well-edited, good transitions, appropriate graphics, good shots, and audible audio
CONFIDENCE
EXCELLENT
Exhibited all (6)
postexamination
activities
VERY
SATISFACTORY
Missed one step of
the postexamination
activities
SATISFACTORY
Missed two
steps of the
postexamination
activities
POOR
Missed three or
more steps of the
post-examination
activities
EXCELLENT
Demonstrated
all (4) qualities
of performance
VERY
SATISFACTORY
Demonstrated
three
qualities of
performance
VERY
SATISFACTORY
Performed entire
procedure with
SATISFACTORY
Demonstrated
two qualities of
performance
POOR
Demonstrated one
or none of the
qualities of
performance
SATISFACTORY
Performed
entire
procedure with
POOR
Not able to perform
entire procedure
with confidence
EXCELLENT
Performed
entire
procedure with
6
TIMING (AT LEAST 45 MINUTES)
great
confidence
EXCELLENT
Performed
entire
procedure
within the
allotted time
(20 minutes)
moderate
confidence
VERY
SATISFACTORY
Performed entire
procedure with 5
minutes excess on
the allotted time
minimal
confidence
SATISFACTORY
Performed
entire
procedure with
10 minutes
excess on the
allotted time
POOR
Performed the
entire procedure
with 15 minutes or
more excess of the
allotted time.
TOTAL
Note: Refer to your textbook for the rationale of each area of assessment.
Perfect Score: 56 points
Range of Scores:
54 - 56 --------------------------------------- Excellent
51 – 53 --------------------------------------- Very Satisfactory
48 – 50 --------------------------------------- Satisfactory
47 and below ------------------------------- Poor
Assessed by:
___________________________________
Name and Signature of RLE Instructor
/rsp
5/30/21
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