Abdominal assessment 1
MENNONITE COLLEGE OF NURSING
AT ILLINOIS STATE UNIVERSITY
NUR 431 Diagnostic Reasoning for Advanced Nursing Practice
Abdominal Assessment
Abdominal complaints are a frequent chief complaint of patients evaluated by NPs.
Remember...
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Be consistent with technique
Thorough history & physical examination (see lab module) may avoid unnecessary diagnostic tests.
Abdomen: General Overview
• Gastrointestinal System
– Stomach
– Small intestine
– Liver
– Gall bladder
– Pancreas
– Large intestine
– Appendix
• Urinary System
– Kidneys
– Ureters
– Bladder
– Urethra
• Reproductive System
– Prostate
– Uterus
– Ovaries
– Fallopian tubes
– Cervix
• Other
– Aorta/Vasculature
– Spleen
Types of Abdominal Pain
• Obstruction
• Peritoneal irritation
• Vascular disorders
• Mucosal ulceration or irritation
• Altered bowel motility
• Capsular expansion
• Metabolic disturbances
• Nerve injury
Abdominal assessment 2
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Muscle wall diseases
Referred pain
Psychopathology
Abdominal Pain: Differential Diagnosis
• Appendicitis
• Cholecystitis
• Pancreatitis
• Perforated ulcer
• Diverticulitis
• Intestinal obstruction
• Volvulus
• Leaking abdominal aneurysm
• Biliary stones, colic
• Salpingitis
• Ectopic pregnancy – LMP?
• Pelvic inflammatory disease (PID)
• Ruptured ovarian cyst
Common Symptoms of Abdominal Disease: Pain
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Origin of abdominal pain
– pain due to tension
– pain due to ischemia
– pain due to peritoneal irritation
Onset
Onset of Pain: Immediate Onset
• Perforated ulcer
• Cholecystitis
• Pancreatitis
• Mesenteric infarction
• Intestinal obstruction
• Ruptured aneurysm
• Ureteral stone
• Diverticulitis
• Perforated colon
• Appendicitis
• Incarcerated hernia
• Ruptured ectopic pregnancy
Onset of Pain: Gradual Onset
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Urinary tract infection
Abdominal assessment 3
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Appendicitis
Low mechanical obstruction
Hernia
Abdominal Disease: Nature of the Pain
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Burning (peptic ulcer)
Cramping (biliary colic, gastroenteritis)
Aching (appendiceal irritation)
Knife-like (pancreatitis)
Gradual onset (infection)
Sudden onset (duodenal ulcer, acute pancreatitis, obstruction, perforation)
Common Symptoms of Abdominal Disease: Pain
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Location (referred pain)
Associated symptoms
– Observation of the patient
– Presence of vomiting
– Signs of impending vascular collapse
– Pelvic and/or rectal exam
Other Common Symptoms of Abdominal Disease
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Nausea/vomiting
Changes in bowel movements
Rectal bleeding
Jaundice
Abdominal distention
Mass
Pruritis (elevated bilirubin?)
Fever
Other History Components
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Past medical history
– If surgical history, think adhesions
– Check meds/OTC (NSAIDS - epigastric pain)
Family history
Psychosocial history
– money
– support systems
– alcohol/caffeine intake
Review of Systems
Abdominal assessment 4
• Don’t forget….Date of LMP (include with ALL females of childbearing age)
Objective Assessment of the Client: Examination Components
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Complete set of vital signs (including wt.)
1st Inspection
2nd Auscultation
3rd Percussion
4th Palpation
– light (“scouting mission”)
– then deep
Note: Stay on right side of patient, comfort/relaxation measures important
Inspection
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Landmarks
Skin
– Scars
– Striae (purple with Cushing’s)
Size/shape of abdomen (flat)
– If not flat, then one of the “Seven F’s” is the cause
The 7 F’s
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Fat
Fibroids
Flatus
Fluid
Fetus
Feces
Fatal (tumors)
Inspection
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Symmetry
– masses
– scoliosis
Check for masses, pulsations, musculature, hernias
Engorged vessels
Visible peristalsis
Auscultation
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Where?
– 4 quadrants and epigastric
Abdominal assessment 5
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Bowel sounds
– Normal (5-34X/minute)
– Hyperactive
– Borborygmi
– Sluggish
– Absent
Bruits
– abdominal aorta
– renal arteries
– iliac arteries
– femoral arteries
Friction rubs
– with liver tumor, enlargement
Percussion
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Why and where?
Percussion sounds
– Tympanic (gastric air bubble, gas in bowels)
– Hyperresonant (base of left lung)
– Resonant (normal lung)
– Dull (liver, spleen)
– Flat (thigh)
Palpation
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Warm hands appreciated!
Watch the patient’s face for signs of pain or discomfort. Think of the underlying organs.
Light
Deep
– tenderness, voluntary guarding, rigidity
– rebound
– liver, spleen, kidneys, aorta, hernia
Special Tests
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Iliopsoas test
– Pain elicited when supine patient attempts to flex thigh against resistance of examiner’s hand
Obturator test
– Supine patient, flex thigh to 60 degrees
– Pain on internal rotation indicates inflamed obturator internus muscle due to perforated intrapelvic
appendix
Others; Murphy’s sign (GB) and Rovsing’s sign (appendix)
Other Examination Considerations
Abdominal assessment 6
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Rectal exam
– every year after age 50 with 10-year life expectancy (ACS; USPSTF-insufficient evidence)
– fecal occult blood - yearly after age 50 (ACS); discontinue at 76+ if no indications and 85+
regardless (USPSTF)
– sigmoidoscopy - every 5 years after 50 (ACS); discontinue as above (USPSTF)
– colonoscopy – every 10 years after age 50 (ACS); discontinue as above (USPSTF)
– with poorly differentiated abdominal pain, may find retrocecal appendix
Pelvic exam - with pain below the umbilicus (STD, PID)
Prostate exam
Labs
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Urinalysis
Urine HCG
CBC
Chemistries
Amylase
Radiographs (x-rays)
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Flat plate
Upright chest x-ray
How does the NP sort out all of this stuff?
If not normal, then...
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Acute Etiologies
– Surgically emergent
• appendicitis
• ectopic pregnancy
• intestinal obstruction
• acute cholecystitis
– Medically emergent
• acute pancreatitis
– Self-limiting (gastroenteritis)
Chronic etiologies
– Cancer of stomach or pancreas
– Irritable bowel syndrome
– Hepatitis
– What to keep and what to REFER?
• Refer anything not sure of