NUR 103
Health Assessment
The Abdomen
Objectives:
• Define terminology related to assessment of the
abdomen.
• Describe anatomy and physiology of abdomen.
• Identify equipment.
• Identify positioning.
• Identify techniques.
• Explain the process of performing an assessment of the
abdomen.
• Recognize normal and abnormal assessment data.
• Differentiate between normal and abnormal assessment
data.
Terminology
• Abdomen- a large oval cavity extending from the diaphragm down to
the brim of the pelvis.
• Aneurysm- defect or sac formed by dilation in artery wall.
• Anorexia- loss of appetite.
• Ascites- abnormal accumulation of serous fluid within the peritoneal
cavity.
• Borborygmi- loud gurgling bowel sounds- inc. motility or
hyperperistalsis.
• Bruit- blowing, swooshing sound heard through stethoscope when
artery is partially occluded.
• Cecum- first or proximal part of large intestine.
• Cholecystitis- inflammation of the gallbladder.
• Costal margin- lower border of rib margin formed by dedial edges of
8th, 9th, and 10th ribs.
• Costovertebral angle (CVA)- angle formed by the 12th rib and
vertebral column on posterior thorax, overlying kidney.
• Diastasis recti- midline longitudinal ridge in abdomen, separation of
abdominal rectus muscles.
• Dysphagia- difficulty swallowing.
• Epigastrium- name of abdominal region between the
costal margins.
• Hepatomegaly- abnormal enlargement of liver.
• Hernia- abnormal protrusion of bowel through weakening
in abdominal musculature.
• Inguinal ligament- ligament extending from pubic bone to
anterior superior iliac spine, forming lower border of
abdomen.
• Linea alba- midline tendinous seam joining the abdominal
muscles.
• Paralytic ileus- complete absence of peristaltic
movement.
• Peritoneal friction rub- rough grating sound heard
through stethoscope over site of peritoneal inflam.
• Peritonitis- inflam. of peritoneum.
• Pyloric stenosis- congenital narrowing of pyloric sphincter, forming
outflow obstruction of stomach.
• Pyrosis- (heartburn) burning sensation in upper abdomen, due to reflux
of gastric acid.
• Rectus abdominis muscle- midline abdominal muscles extending from
rib cage to pubic bone.
• Scaphoid- abnormally sunken abdominal wall.
• Splenomagaly- abnormal enlargement of spleen.
• Striae- (linia ablicantes)- silvery white or pink scar.
• Suprapubic- name of abdom. Region just superior to pubic bone.
• Tympany- high-pitched, musical, drumlike percussion note heard when
percussing over stomach and intestine.
• Umbilicus- depression on abdom. Marking site of entry of umbilical cord.
• Viscera- internal organs.
• Solid viscera- characteristic shape (liver, pancreas, spleen, adrenal
glands, kidneys, ovaries, and uterus).
• Hollow viscera- shape depends on contents (stomach, gallbladder, small
intestine, colon, and bladder).
Anatomy of the Abdomen
Divided into 4 quadrants
Right upper quadrant:
Liver
Gallbladder
Duodenum
Head of Pancreas
Right kidney and adrenal
Hepatic flexure of colon
Part of ascending & transverse colon
Left upper quadrant:
Stomach
Spleen
Left lobe of liver
Body of pancreas
Left kidney & adrenal
Splenic flexure of colon
Part of transverse & descending
colon
Right Lower Quadrant:
Cecum
Appendix
Right ovary and tube
Right ureter
Right Spermatic cord
Left Lower Quadrant:
Part of descending colon
Sigmoid colon
Left ovary and tube
Left ureter
Left spermatic cord
Midline:
Aorta
Uterus (if enlarged)
Bladder (if distended)
The Right Quadrant of the
Abdomen:
The Liver
The liver is located in the
upper
right portion of the
abdominal
Cavity, just below the
diaphragm.
Partially surrounded by the
ribs,
Extends from the level of
fifth Intercostal space
to lower margin of the ribs.
Gallbladder
The gallbladder is a pearshaped sac located in a
depression on the
Inferior surface of the right
hepatic lobe.
Duodenum
The duodenum is part of the small
Intestine. Approx. 25 cm Long
and 5 cm in diameter.
It passes in front of the right kidney
And the upper three lumbar
vertebrae.
Right Kidney
The kidney is a reddish brown, bean
shaped
Organ with a smooth surface. 12 cm long,
6 cm wide, 3 cm thick in adult.
The right kidney lies on the right side of
the vertebral column in a depression high
On the posterior wall of the abdominal
cavity (retroperitoneal).
Right kidney is lower than Left kidney.
Head of pancreas
The pancreas is a soft,
lobulated gland located
behind the stomach. It
extends horizontally across
the posterior Abdominal wall
with its head in the C-shaped
curve of the duodenum and
its tail against the Spleen.
Hepatic flexure of colon, part of
ascending and transverse colon:
Ascending-Portion of the large
Intestine that passes
Upward on the right
Side of the abdomen
From the secum to the
Lower edge of the liver.
Transverse- extends across
Abdomen from right to left below
Stomach.
Left Upper Quadrant:
Stomach:
Digestive organ located between
the esophagus and the small
intestine.
The Spleen:
A soft mass of lymphatic
Tissue on posterolateral
Wall of abdominal cavity,
Immed. Under diaphragm.
Lies obliquely, with long axis
Behind and parallel to 10th rib.
Lateral to midaxillary line.
Continuation of left quadrant of abdomen:
Left lobe of liver:
Body of pancreas:
Left kidney and adrenal
Splenic flexure of colon
Part of transverse and
Descending colon
Right Lower Quadrant of
Abdomen
• Cecum
• Appendix
• Right ureter
• Right spermatic cord
• Right ovary and tube
Left Lower Quadrant
of the Abdomen:
Part of descending colon
Sidmoid colon
Left ovary and tube
Left ureter
Left Spermatic cord
Midline
Anatomy of Abdomen:
Aorta
Uterus (if enlarged)
Bladder ( if distended)
EQUIPMENT
• Proper lighting: include strong overhead
light and secondary stand light.
• Stethoscope
• Small centimeter ruler
• Skin-marking pen
• Alcohol swab (to clean endpiece)
Positioning:
•Position the person supine, with
head on
a pillow, knees bent or on pillow,
and arms
at sides or across the chest.
Note: Discourage person from
placing arms
Over the head because this
tenses abdom.
Musculature.
Techniques:
•
•
•
•
•
•
Provide strong lighting
Have person empty bladder
Keep room warm to avoid chilling & tensing of muscles
Position person supine
Warm stethoscope and hands to avoid abdom. Tensing.
Inquire re: painful areas, examine such area last to avoid
musculature guarding.
• Finally, learn distraction tech. Enhance muscle relaxation
through breathing exercises, emotive imagery, low,
soothing voice, allowing person to relate abdominal hx
while you palpate.
Inspection:
Inspection of abdomen:
•
Normal Findings:
• Abnormal Findings:
Contour
1. Stand on person’s right
side, look on abdomen.
2. Your head should be slightly
higher than abdom.
3. Determine profile from rib
3. Scaphoid abdomen,
margin to pubic bone.
protuberant abdomen,
Contour describes nutitional
abdominal distention.
state. Normal ranges from
flat to rounded.
Symmetry of Abdomen
•
1.
2.
3.
4.
5.
Normal Findings:
Shine a light across abdom.
toward you, or shine lengthwise
across person.
Abdomen should be symmetric
bilaterally.
Even small bulges are
highlighted by shadow.
Step to foot of examination
table to recheck symmetry.
Ask person to take deep breathfurther highlight any change.
Abdom. Should stay smooth
and symmetric.
• Abnormal Findings:
2. Bulges, masses
3. Hernia- protrusion of abdom.
Viscera through abnormal
opening in muscle wall.
Note any localized bulging.
Hernia, enlarged liver or spleen may
show.
Inspection of Umbilicus:
•
Normal Findings:
1. Normally at midline,
inverted, no sign of
discoloration, inflam., or
hernia,.
Becomes everted and
pushed upward with
pregnancy.
•
Abnormal Findings:
1. Everted with acites, or
underlying mass.
2. Deeply sunken with
obesity.
3. Enlarged and everted
with umbilical hernia.
4. Bluish periumbilical
color occurs with
intraabdominal bleeding
(Cullen’s Sign)
Inspection of skin
•
1.
Normal Findings:
Surface smooth, even,
homogeneous color.
2.
Striae- pink, or blue, then silvery
white pigment changes.
3.
Moles-circumscribed brown
macular or papular areas.
4.
No lesions present. May have wellhealed surgical scar, draw location
in pt. record, indicating length in
cm.
5. Veins usually not seen, fine venous
network may be visible in thin
persons.
6.
Good skin turgor- healthy nutrition.
Pinch up fold of skin, release to note
skin’s
Immediate return to original position.
•
1.
2.
3.
4.
5.
Abnormal Findings:
Redness with localized
inflammation, jaundice, Skin
glistening and taut (ascites).
Striae look purple-blueCushing’s Syndrome (excess
adrenocortical hormone causes
skin to be fragile).
Unusual color or change in
shape of mole. Petechiae.
Cutaneous angiomas (spider
nevi) occur with portal HTN or
liver disease.
Lesions, rashes. Prominent,
dilated veins- portal HTN,
cirrhosis, ascites, or vena caval
obstruction. Veins more visible –
malnutrition due to thinned
adipose tissue.
Pulsation or movement:
• Normal Findings:
1. Pulsations normally
seen from aorta
beneath skin in
epigastric area.
2. Respiratory movement
in abdomen (males).
3. Waves of peristalsis in
very thin persons.
(ripple slowly & obliquely
across abdom.)
• Abnormal Findings:
1. Marked pulsations of
aorta occurs with
widened pulse pressure
(HTN, aortic insuff.,
thyrotoxicosis) & aortic
aneurysm.
3. Marked visible
peristalsis, with
distended abdomenintestinal obstruction.
Inspection of abdomen
Hair distribution, Demeanor
• Normal Findings:
1. Pubic hair growth
normally diamond
shape in adult males,
inverted triangle shape
in females.
2. Demeanor- comfortable
person relaxed on
exam. Table, a benign
facial expression, slow,
even resp.
• Abnormal Findings:
1. Patterns alter with
endocrine or hormone
abnormalities, chronic
liver diseases.
2. Restlessness, constant
turning to find a
comfortable position
occur with colicky pain
of gastroenteritis or
bowel obstruction.
Auscultation of Abdomen
Note: Perform auscultation next because percussion and palp.
can increase peristalsis, which could give false interpretation
Of bowel sounds.
Bowel Sounds and Vascular Sounds:
1. Use diaphragm endpiece- Bowel sounds
are high pitched.
2. Hold stethoscope lightly against skin
(pushing too hard may stim. More bowel
sounds.
3. Begin in RLQ at ileocecal valve area (bowel
sounds are almost always present here
normally).
Bowel Sounds
• Normal Findings:
1. Note character of bowel
sounds. Wide range of
normal sounds, irreg.
(5-30 times/min.)
2. Borborygmus- type of
hyperactive bowel
sound fairly common.
(when you feel your
stomach growling).
3. Note: you must listen for
5 min. before deciding if
BS are completely
absent.
• Abnormal Findings:
1. Two distinct abnorm.
sounds:
A. Hyperactive- loud, highpitched, rushing, tinkling
sounds-signal
inc.motility.
B. Hypoactive-or absent
sounds.
Vascular Sounds
• Normal Findings:
1. As you listen, note
presence of vscular
sounds or bruits.
2. Using firmer pressure,
check over aorta, renal
arteries, iliac, and
femoral arteries. No
sound is normal.
• Abnormal Findings:
1. Note location, pitch, and
timing of vascular
sound.
2. Systolic bruit is pulsatile
blowing sound, occurs
with stenosis or
occlusion of artery.
3. Venous hum, peritoneal
friction rub are rare.
Vascular Sounds
Femoral
artery
Percussion of abdomen:
General tympany, liver span,
splenic dullness.
Percussion:
• To assess relative
density of
abdominal
contents, to locate
organs, and to
screen for
abnormal fluid or
masses.
General Tympany
• Normal Findings:
1. First, percuss lightlyall four quad. to
determine amt.
tympany & dullness.
2. Tympany should
predominate.
• Abnormal Findings:
1. Dullness occurs over
distended bladder,
adipose tissue, fluid, or
mass.
2. Hyperresonance is
present with gaseous
distention
Liver Span
•
1.
2.
3.
4.
5.
Normal range of findings:
Next, map out boundaries of certain
organs.
Measure ht. of liver in right midclavicular
line.
Begin in area of lung resonance, percuss
down interspaces until sound changes to
dull quality.
Mark the spot (usually in 5th intercostal
space. Then find abdom. Tympany &
percuss u midclavicular line. Mark where
sound changes from tympany to dull
sound, normally at right costal margin.
Measure distance between two marks;
normal liver span in adult ranges from 612 cm. Height of liver span correlates ht.
of person, taller have longer livers.
•
Abnormal Findings:
2. Enlarged liver span
indicates liver
enlargement or
hepatomegaly.
3. Accurate detection of liver
borders is confused by
dullness above the 5th
intercostal space (Lung
disease, e.g.,pleural
effucion or
consolidation.) Accurate
detection at lower border
is confused when
dullness is pushed up
with ascites or pregnancy
or gas distention in colon.
Normal range of findings, cont’d.
• One variation occurs with chronic emphysema, which the
liver is displaced downward by hyperinflated lungs.
Although dull percussion is noted well below right costal
margin, the overall span is still WNL’s.
• Clinical estimation of liver span is important to screen for
hepatomegly & to monitor changes in liver size.
Measurement is a gross estimate, liver span may be
underestimated because of inaccurate detection of upper
border.
• Scratch test- final tech. may help define liver border
when abdom. Is distended or abdom. Muscles are tense.
Splenic Dullness
•
1.
2.
Normal Findings:
Spleen is obscured by stomach
contents, may locate by
percussing for dull note from
9th-11th intercostal space behind
left midaxillary line.
Now, percuss in lowest
interspace in left anterior
axillary line. Tympany should
result. Ask person to take deep
breath, normally, tympany
remains through full inspiration
•
1.
2.
Abnormal Findings:
Dull note forward of midaxillary
line indicates enlargement of
spleen (mononucleosis, trauma,
infection).
In this site, anterior axillary line,
change in percussion from
tympany to dull sound wit full
inspiration is positive spleen
percussion sign, indicating
splenomagaly. This method will
detect mild to mod.
Splenomegaly before spleen
becomes papable
(mononucleosis, malaria, or
hepatic cirrhosis).
Costovertebral Angle Tenderness
•
• Normal Findings:
1. Indirect fist percussion 1.
causes tissues to
vibrate instead of
producing a sound.
2. To assess the kidney,
place one hand over
the 12th rib at the CVA
on the back. Thump
that hand with the
ulnar edge of other
fist. No pain elicited.
Abnormal Findings:
Sharp pain occurs with
inflammation of kidney
or paranephric area.
Special Procedures:
Ascites
•
1.
Fluid Wave:
First, test for a fluid wave by
standing on person’s right side.
Place ulnar edge of another
examiner’s hand on abdomen in
midline. Place left hand on person’s
right flank. With right hand, reach
across abdomen and give the left
flank a firm strike. If ascites is
present, the blow will generate a
fluid wave through the abdomen, &
feel distinct tap on left hand. If
distended from gas or adipose
tissue, no change.
• Shifting Dullness:
1. In a supine position, ascitic fluid
settles by gravity into the flanks,
displacing air-filled bowel upward.
You will hear a tympanitic note as yu
percuss over the top of abdomen
because gas-filled intestines float
over the fluid.
2. Then percuss down side of
abdomen. If fluid is present, the note
will change from tympany to dull as
you reach its level.
3. Now turn pt. to right side (roll toward
you). Fluid will gravitate to
dependent side. Begin percussing
upper side of abdomen and move
downward. Sound changes from
tympany to dull sound as you reach
fluid level. This level of dullness is
higher, upward toward the umbilicus.
Palpation of Abdomen
1. Palpation is performed to judge the size, location, & consistency of certain
organs & to screen for an abnormal mass or tenderness.
Technique for palpation
1.
2.
3.
4.
5.
6.
7.
Bend the person’s knees.
Keep palpating hand low & parallel to abdomen.
Teach pt. to breathe slowly (in through nose, out
through mouth).
Keep your own voice low & soothing. Conversation
may relax the pt.
Try “emotive imagery”.
Keep pt.’s hand under your finger curled over his/her
fingers for very ticklish person. People are not ticklish
to themselves.
Alternatively, perform palpation just after auscultation.
Keep stethoscope in place & use stethoscope until pt.
is used to being touched.
Light palpation:
•
1.
2.
3.
4.
5.
6.
Normal Findings:
Begin with light palpation.
With first four fingers close
together, depress skin about 1
cm. Make gentle rotary motion,
sliding fingers & skin together.
Lift fingers, do not drag them, &
move clockwise to next location
around abdom.
Objective here is not to search
for organs but to form overall
impression of skin surface &
superficial musculature.
Save exam of identified tender
areas until last.
Determine if voluntary muscle
guarding & involuntary rigidity.
•
1.
2.
3.
4.
5.
Abnormal Findings:
Muscle guarding
Rigidity
Large masses
Tenderness
Involuntary rigidity is constant
board like hardness of muscles.
Deep palpation
•
1.
2.
3.
4.
Normal Findings:
Same tech. as light palp., but
push down 5-8 cm (2-3 in.)
moving clockwise, exploring
entire abdomen.
To overcome resistance of very
large or obese abdomen, use
bimanual tech.
Place two hands on top of ea.
Other. Top hand does pushing;
bottom hand is relaxed,
concentrating on sense of
palpation.
Note location, size, shape,
consistency (soft, firm, hard),
surface (smooth, nodular),
Mobility (including movement
with respiration), pulsatility,
tenderness
• Abnormal Findings:
1. Tenderness occurs with local
inflammation, with inflammation
of peritoneum or underlying
organ, & with an enlarged organ
whose capsule is stretched.
2. Abnormal enlargement.
3. Tenderness.
4. Masses.
Palpation of Liver
•
1.
2.
3.
4.
Normal Findings:
Place left hand under
person’s back parallel to 11th
& 12th ribs and lift up to
support abdominal contents.
Place deeply down & under
right costal margin.
Ask person to take a deep
breath.
Normal to feel edge of liver
bump fingertips as
diaphragm pushes it down
during inhalation. Feels like
firm regular ridge. May not be
palpable, may feel nothing.
• Abnormal Findings:
1. Except for depressed diaphra,
l liver palpated more than 1-2
cm below right costal margin is
enlarged.
2. Record number in cm it
descends & note consistency
(hard, nodular), and
tenderness.
Palpation of spleen
•
1.
2.
3.
4.
Normal Findings:
Normally spleen is not palpable,
must be enlarged three times its
normal size to be felt.
To find, reach your left hand
over abdomen & behind the left
at 11th & 12th ribs. Lift up for
support.
Place right hand obliquely on
LUQ with fingers pointing toward
left axilla & just inferior to rib
margin.
Push hand deeply down & under
left costal margin & ask person
to take deep breath. You should
feel nothing firm.
• Abnormal Findings:
1. Spleen enlarges with
mononucleosis and trauma.
2. Describe number of cm it extends
below left costal margin.
3. When spleen is enlarged, it slides
out & bumps fingertips. Can grow
so large that it extends into lower
quadrants.
4. May roll person onto right side to
displace spleen more forward &
downward.
Palpation of kidneys
•
1.
2.
3.
Normal Findings:
Search for right kidney by placing
hands together in a “duck-bill”
position at person’s right flank.
Press two hands together firmly &
ask person to take deep breath. In
most people, feel no change. Occ.
You feel lower pole of right kidney
as round, smooth mass slide
between fingers. Either is normal.
Left Kidney sits 1 cm higher than
right, not palpable normally. Locate
by reaching left hand across
abdom. & behind left flank for
support. Push right hand deep into
abdom. And ask person to breathe
deeply. You should feel no change
with inhalation.
•
1.
2.
Abnormal Findings:
Enlarged kidney
Kidney mass
Palpation of aorta
• Normal Findings:
1. Using opposing thumb
& fingers, palpate
aortic pulsation in
upper abdomen
slightly to left of
midline.
2. Normally- 2.5-4 cm
wide in adult, pulsates
in anterior direction.
• Abnormal Findings:
1. Widened with
aneurysm
2. Prominent lateral
pulsation with aortic
aneurysm.
Special procedures for abdominal
palpation:
• Normal Findings:
1. Rebound tenderness:
(Blumberg’s Sign)-Assess
when person reports
abdom. Pain or when elicit
tenderness during
palpation.
Hold hand perpendicular to
abdom., push down slowly
and deeply, lift up quickly.
A normal, or negative
response is no pain on
release of pressure.
• Abnormal Findings:
1. Pain on release of
pressure confirms rebound
tenderness, reliable sign of
peritoneal inflammation.
Murphy’s Sign (Inspiratory arrest)
• Normal Findings:
1. Normally, palpating
will cause no pain.
2. Ask person to take
deep breath. Hold
fingers under liver
border.
3. A normal response
is to complete deep
breath without pain.
• Abnormal Findings:
1. Positive test: as
descending liver
pushes inflamed
gallbladder onto
examining hand,
person feels sharp pain
& abruptly stops
inspiration midway.
Iliopsoas Muscle Test
• Normal Findings:
1. Perform when acute
abdom. Pain of
appendicitis is
suspected.
2. With pt. in supine pos.,
lift right leg straight up,
flexing at hip, then push
down over lower part of
right thigh as person
tries to hold leg up.
3. Negative test when pt.
feels no pain
• Abnormal Findings:
• When iliopsoas muscle is
inflamed (Inflamed or
perforrated appendix),
pain is felt in right lower
quadrant.
Obiturator Test
• Normal Findings:
• Test done when
appendicitis is suspected.
• With person supine, lift
right leg, flexing at hip,
and 90 degrees at knee.
Hold ankle & rotate leg
internally & externally.
• Negative or normal is no
pain.
• Abnormal Findings:
1. Perforated appendix
irritates the obturator
muscle, producing pain.
Developmental Considerations:
•
Normal Findings in the
infant, child, adolescent,
and aging adult:
• Abnormal Findings:
• Scaphoid shape occurs with
dehydration in infant and
child. Dilated veins.
• Only one artery in umbilical
cord in infant, inflammation,
drainage after cord falls off.
• Under 7 yrs., absence of
abdom. Resp. occurs with
inflammation of peritoneum.
• Abdom. Rigidity with acute
abdom. Conditions less
common in aging persons.
• Acute abdom, aging person
complains of less pain than
younger person.