Abdominal Assessment

1. Abdominal Assessment

2. Abdominal Surface Anatomy Use the appropriate terminology to locate your findings For practical purposes it is easiest to think of the abdomen divided into four quadrants with the umbilicus at the center Right Upper Quadrant RUQ Left Upper Quadrant LUQ Right Lower Quadrant RLQ Left Lower Quadrant LLQ Note that the names refer to the person's left or right side

3. Abdominal Surface Anatomy

4. Abdominal Surface Anatomy There are additional terms for midline findings Epigastric Periumbilical Suprapubic

5. Abdominal Surface Anatomy

6. Internal Anatomy Most of the abdominal organs are found within the peritoneum These organs can and do move (during pregnancy or after surgery for example)

7. Internal Anatomy: Peritoneal

8. Internal Anatomy Certain structures, such as the kidneys and pancreas, are retroperitoneal Problems with these structures often present with signs and symptoms very different from the "true" abdominal organs.

9. Internal Anatomy: Retroperitoneal

10. Relevant History Personal History Weight changes and time frame Current weight Usual weight Highest weight Lowest weight Changes in appetite Food allergies or intolerances

11. Relevant History Food supplements Vitamins Minerals Herbals Calorie/protein supplements Diet 24-hour recall 3 or 7-day food diary Typical diet

12. Relevant History Changes in Appetite Anorexia Polyphagia

13. Relevant History Problems with digestion Eructation Belching Pyrosis Heartburn Nausea with and without emesis

14. Emesis: Vomiting Characteristics of vomitus Partially digested food Undigested food Fecal material Frank blood “Coffee grounds” Timing of emesis Meals, Activities

15. Relevant History Changes in bowel habits Diarrhea Constipation Alternating diarrhea and constipation Frank blood in stools Tarry stools

16. Relevant History Abdominal Pain Timing Course Location Quality Radiation

17. Quality of Abdominal Pain Pain from Hollow Viscera Often referred to as a "colic“ Quite common. Characteristics Crampy/paroxysmal Often poorly localized Related to peristalsis Person often writhes in pain

18. Quality of Abdominal Pain Pain from Peritoneal Irritation More ominous Associated with peritonitis from any cause Peritonitis - infection or irritation of the peritoneum - a sign of profound problems

19. Quality of Abdominal Pain Characteristics Steady/constant Often well localized Not related to peristalsis Person lies still with knees up

20. Radiation of Abdominal Pain Abdominal pain is not always confined to the abdomen Because of the complex way organs migrate during embryological development, pain pathways are often "crossed" with other areas Pain which manifests at a site distant from the actual pathology is called "referred" pain

22. Appendicitis Appendicitis is a serious and relatively common disorder in children and young adults (although it can occur at any age) The position of the appendix is highly variable The pain associated with appendicitis varies with the anatomy

23. Cholecystitis Cholecystitis means literally inflammation ('itis') of the gall bladder." This is most often due to complete or partial obstruction of the bile ducts by gall stones It can also include infection and necrosis, both very serious complications

24. Renal Colic The kidneys can harbor stones for many years without causing discomfort They can become quite large (many cms) and not cause any immediate problem When a stone or stone fragment becomes lodged in the ureter the person will experience acute renal colic

25. Physical Examination

26. Equipment and Techniques Equipment Stethoscope Techniques Inspection Auscultation Percussion Palpation

27. General Tips The person should have an empty bladder The person should be lying supine appropriately draped The examination room must be quiet to perform adequate auscultation and percussion The examiner should be on the person’s right side to most effectively assess the abdomen Watch the person's face for signs of discomfort during the examination

29. Inspection

30. Inspection Examine the skin for scars, striae, hernias, vascular changes, lesions, or rashes

31. Inspection Examine the general configuration of the abdomen Look for movement associated with peristalsis or pulsations Note the abdominal contour. Is it flat, scaphoid, or protuberant?

32. Inspection It is particularly important to note any scars and correlate these with the person's past surgical history, certain disorders (obstruction, adhesions) are more common after abdominal surgery.

33. Auscultation

34. Auscultation: Bowel Sounds Auscultation should be done prior to percussion and palpation since bowel sounds may change with manipulation Bowel sounds are transmitted widely in the abdomen, therefore auscultation of more than one quadrant is not usually necessary If you hear them, they are present, period

35. Auscultation: Bowel Sounds HOWEVER In order to say with certainty that there are NO bowel sounds present you must listen in all 4 quadrants for 5 minutes

36. Auscultation: Bowel Sounds Place the diaphragm of stethoscope lightly on the abdomen

37. Auscultation: Bowel Sounds Normal bowel sounds Clicks and gurgles Irregular Every 5-35 seconds Increased bowel sounds Hyperactive Borborygmi Decreased bowel sounds Hypoactive

38. Auscultation: Bruits What’s wrong with this picture?

39. Reflexes

40. Superficial Abdominal Reflexes Use a blunt object such as a key or tongue blade Stroke the abdomen lightly on each side in an upward and outward direction above (T8, T9, T10) the umbilicus Stroke in a downward and outward direction below the umbilicus (T10, T11, T12) Note the contraction of the abdominal muscles and deviation of the umbilicus towards the stimulus

41. Superficial Abdominal Reflexes

42. Percussion

43. Percussion: General A useful first survey of the abdomen prior to palpation Percuss in all four quadrants

44. Percussion: General Categorize what you hear as tympanic or dull Tympany is normally present over most of the abdomen in the supine position (due to intestinal gas Unusual dullness may be a clue to an underlying abdominal mass, for example and enlarged liver or impacted stool

45. Palpation

46. Palpation Begin with light palpation. At this point you are mostly looking for areas of tenderness Voluntary or involuntary guarding may also be present The most sensitive indicator of tenderness is the persons facial expression Soooo - watch the person's face, not your hands!!

47. Light Palpation

48. Palpation What is the difference between tenderness and pain? Tenderness is discomfort caused or increased by their examination (a sign) Pain on the other hand, is something the person tells you about as part of the history (a symptom)

49. Palpation Proceed to deep palpation after surveying the abdomen lightly This is contrary to what Ignatavicius & Workman state – you DO perform general deep palpation, carefully, if light palpation is negative Try to identify abdominal masses or areas of deep tenderness

50. Deep Palpation

51. Palpation of the Aorta Press down deeply just left of the midline above the umbilicus The aortic pulsation is easily felt on most individuals A well defined, pulsatile mass, greater than 3 cm across, suggests an aortic aneurysm

52. Palpation of the Aorta

53. Palpation of the Aorta Try to differentiate between an abdominal pulse and a pulsatile abdominal mass Unless the person is particularly thin, under normal circumstances you should be able to feel an abdominal pulse without any "structure" to it If you detect an easily palpable, pulsating abdominal mass it is likely to be an aneurysm.

54. Special Tests Rebound Tenderness This is a test for peritoneal irritation Warn the person what you are about to do Press deeply on the abdomen with your hand After a moment, quickly release pressure If it hurts more when you release, the person has rebound tenderness.

55. Rebound Tenderness

56. Special Tests Costovertebral angle tenderness (CVAT) is often associated with renal disease. Warn the person what you are about to do Have the person sit up on the exam table Use the heel of your closed fist to strike the person firmly over the costovertebral angles Compare the left and right sides Tenderness in these areas indicates renal inflammation, most often an infection.

57. CVAT

58. Developmental Variations Infants Synchronous chest and abdominal movements with breathing Superficial veins seen in premature and thin infants Pulsations in epigastric area are common Liver palpable 1-3 cm below costal margin Abdomen is rounded and protrudes in young children

59. Developmental Variations Adolescents Tanning lines and fine venous networks are often visible Flat contour common

60. Developmental Variations Pregnancy Nausea and vomiting common Diminished abdominal reflex Peristalsis decreases Abdominal striae Linea nigra Diastasis recti

61. Diastasis Recti Diastasis is a separation of the two halves of the rectus abdominis muscle on the middle of the abdomen Have person in supine position Place your fingertips 1-2 inches below the umbilicus Have the person lift her head as high as she can Feel for a separation and estimate 1 fingerbreadths, 2 fingerbreadths, etc.

62. Diastasis Recti

63. Developmental Variations Elderly Decreased intestinal motility Abdominal wall thinner and less firm Fat pad common Loss of muscle tone Midclavicular liver span is decreased Hepatic blood flow and liver cell # decrease Some drugs may not be metabolized as well

64. Questions???

65. Here’s Some for You! List the seven topographal areas of the abdomen. Describe normal peristalsis. List, in order, the steps in physically assessing the abdomen. Describe how you would evaluate a person for abdominal pain.