Faculty of Nursing-IUG

1. Faculty of Nursing-IUG Chapter (11) Assessment of the abdomen

2. Assessment of the abdomen • The abdomen is the largest body cavity that extends from the diaphragm inferiorly to the inlet of the true pelvis. Its contents are partially protected: • Superiorly by the lower ribs. • Posterior by the lumbar vertebra. • Laterally by the iliac bones Abdomen Regions • Divisions of the abdomen • Four Quadrants. • Nine regions.

3. Locating Abdominal Structure By Quadrant 1. Right Upper Quadrant (RUQ) • Ascending and transverse colon • Duodenum Gallbladder • Liver , head of pancreas Right of adrenal gland • The small intestine or ileum in all quadrant • Right kidney (upper pole) and right ureter 2. Right Lower Quadrant (RLQ) • Appendix • Ascending colon , Cecum • Right kidney lower pole • Right ovary and tube, right ureter, and right spermatic cord

4. 3. Left Upper Quadrant (LUQ) contains of: • Left of adrenal gland • Left kidney (upper pole) • Left ureter Pancreas (body and tail) • Spleen Stomach • Transverse ascending colon 4. Left Lower Quadrant (LLQ) contains of: • Left kidney (lower pole) • Left ovary and tube • Left spermatic cord • Sigmoid colon 5. Midline • Balder , Uterus , Prostate gland

5. Assessment Procedures Subjective data: ask the client about: • Nutritional history: appetite, weight loss or gain. • Gastro intestinal symptoms: dysphagia, nausea, vomiting, and indigestion. • Bowel habits: pattern, and stool characteristics. • Pain: location, quality, pattern, and relationship to ingestion of food. • Use of medications: Aspirin, Anti inflammatory drugs, and steroids. • Gastro intestinal diagnostic tests and surgeries. • The client is placed in the supine position, with small pillows under the head and knees. • The abdomen is exposed from the breast to the symphysis pubis • Start assessment with inspection, auscultation, then percussion and palpation. • Stand the client right side and carry out assessment systematically, beginning with the left upper quadrant. The bladder should be empty.

6. Inspection: • Under source of light you see exactly changes in contours. • Assess the presence or absence of symmetry, distention, masses, visible peristaltic waves and respiratory movement. • Inspect the abdominal skin for pigmentation e.g. jaundice, lesions, striae scars, dehydration, general nutritional status and condition of umbilicus, this give information about general state health • Contour of the normal abdomen is described as: flat, rounded, or scaphoid. Normally contour is description of the profile line from the rib margin to the pubic bone. • Flat contour seen in the muscularly competent and well nourished individual. • Rounded abdomen: Normally in infant and toddler, but in the adult caused by poor muscle tone and excessive Subcutaneous fat deposition. • Scaphoid contour “Concave in horizontal line” seen in thin clients of all ages. • Inspect for respiratory movements especially for retraction of the abdominal wall on inspiration which is called "Czerny's sign “associated with some Central Nervous System diseases such as chorea”

7. Auscultation: • Auscultate peristaltic sounds which are normally high pitched. • Listen for at least "5" minutes before concluding that no bowel sounds are present. "Peristaltic sounds may be quite irregular". • Duration of single sound may be less than a second or more than it. • Stimulation of peristalsis may be achieved by flicking the abdominal wall with a finger “direct percussion • Auscultate vascular sounds: Loud bruits detected over the aorta may indicate presence of an aneurysm; the aorta is auscultated superior to the umbilicus • Listen for Peritoneal friction rub over the area of liver and spleen e.g. spleen infection, abscess or tumor: best heard over the lower rib cage in the anterior axillary line. (rough grating sound like sound of two pieces of leather being rubbed together).

8. Percussion: • To detecting fluid or gaseous distention and masses and assessing solid structures within the abdomen. • Percussion of one for each quadrant to assess areas of tympany and dullness. Potentially painful areas are always Percuss last • Percussion allows you to identity borders of the liver to detect organ enlargement. • To detect liver size, start percussion at the right iliac crest and proceeds up ward on the right mid-clavicular line, when dullness occur this is the lower border of the liver. • To detect upper border of the liver percuss, down from the nipple along mid-clavicular line, then dullness occur “upper border” may be found in (5,6,7) intercostals space, distance between points lower and upper is (6-12cm). Diseases e.g. cirrhosis, cancer, and hepatitis cause liver enlargement Stomach position: • With percussion you can locate the tympanic air bubble of the stomach by percussing over the left lower anterior rib cage.

9. Kidney Tenderness: • In sitting or erect position, use direct or indirect percussion to assess for kidney inflammation. • Use ulnar surface of the partially closed fist and percuss the costo-vertebral angle at the scapular line. • If the kidneys are inflamed, client feels tenderness during percussion Palpation: • Detect abdominal tenderness and noting the quality of abnormal distensions or masses. • During palpation assess for muscular resistance, distention, tenderness and superficial organs or masses. • Assess for distended bladder if client has inability to void (Bladder lies normally below the umbilicus and above symphysis pubis). • In deep palpation depress hands (2.5-7.5 cm), "1-3 inch" Deep palpation never used over a surgical incision or tender organs, or masses. • If tenderness present, check for rebound tenderness, if it was positive indicated peritoneal irritation e.g. appendicitis

10. Palpation of liver: • Right upper quadrant under the rib cage • Place your left hand under client’s posterior thorax at the 11th and 12th ribs and by your right hand palpate in and up to feel the liver’s edge as the client inhales. • G.B normally not felt and if distended it felt under liver and may indicate cholecystitis. Palpation of spleen: • Generally not palpable in normal adult person, but in case of spleen enlargement you can palpate it below costal margin.

11. Assessment of the anus and recto sigmoid region • Events required rectal examination: • Abdominal pain • Alternation in bowel habits. • Anal pain, anal spasm. • Anal itching or burning. • Black tary stool. • Rectal bleeding. • Positions for rectal examinations: • Left lateral or SEM's position. • Knee- chest position • Standing position, most common use for prostate gland examination. • Lithotomy position • Squatting position. • In all positions, before examination wear two gloves

12. Inspection: • Spread buttocks carefully with both hands to examine the anus and skin around it which is more pigmented, moist, and hairless. • Assess lesions, scars, or inflammation, peri-rectal abscess, fissures, piles, fistula opening, tumor and rectal prolapsed. • Ask the client to strain down ward as in defecation. • Inspect for pilonidal sinus or cyst at the sacro- coccygeal area, and give description Palpation: (PR examination) • Spread the buttocks apart with your non dominant hand. Gloved index gently placed against the anal verge, and with firm pressure in direction of umbilicus as the rectal sphincter relaxes. Ask client to lighten the sphincter around your finger to examine muscle strength. • Mucosa of the anal canal is palpated for tumor or polyps. • Assess normal cervix in female which felt as small round mass during P.R examination

13. Common diseases can be detected during rectal examination: • Pilonidal cyst or sinus. • Pruritus anus • Rectal tenesmus:. • Fecal impaction • Anal fissure • Fistula in anus • Hemorrhoids: External painful & internal painless unless complicated. • Rectal polyps • Rectal prolapse: e.g. in case of internal hemorrhoids • Anal incontinence. • Abscesses or masses e.g. Ischio rectal abscess, peri rectal obstruction