PHYSICAL ASSESSMENT OF THE ABDOMEN

1. PHYSICAL ASSESSMENT OF THE ABDOMEN • Dr. Beverly Fineman • Nursing 309

2. OBJECTIVES • At the end of this class, the student will be able to: • Identify landmarks for the abdominal assessment • Correctly perform techniques of inspection, auscultation, percussion and palpation • Differentiate normal from abnormal findings • Document findings

3. Overview of abdominal structure. • large oval cavity • extends from diaphragm to symphysis • viscera: solid and hollow

4. Landmarks for the abdominal examination • four quadrants • nine sections • bony landmarks • muscles

5. More landmarks • Bony landmarks on the anterior body include: • xiphoid process of sternum • costal margin, midline, umbilicus, anterior iliac spine, poupart’s ligament, superior margin of pubis • Posterior landmark • costovertebral angle

6. Abdominal assessment • Preparing the exam room • preparing the patient • positioning the examiner

7. Assessment Techniques • inspection • skin: color, scars, veins, lesions, umbilicus • umbilical hernia, bleeding, inflammation

8. Continued inspection • contour of the abdomen:flat,rounded, protuberant,scaphoid • symmetry • enlarged organ • masses • peristalsis,pulsation,distention

9. distention -Definition: unusual stretching of abdominal wall • note position of umbilicus • note portion of abdomen that is distended • reasons for distention:flat(obesity), flatus(gas), feces, fluid, fetus(pregnancy or tumor)

10. Auscultation • Where it occurs in abdominal assessment • listening for bowel sounds to assess motility • normal sounds • abnormal sounds • how and where to listen

11. Auscultation continued • Auscultation performed before palpation and percussion • Use diaphragm of stethoscope • Listen to bowel sounds • Normal sounds are clicks and gurgles, irregular, 5-30 times per minute • Influenced by digestion

12. More on Auscultation • Increased bowel sounds are due to hypermotility of peristalsis • Decreased are due to paralytic ileus or peritonitis • intestinal obstruction can present with increased or decreased sounds

13. Additional Sounds • Always listen in hypertensive patient • Bruits: • Bruits are low pitched, vascular sounds, resembling murmur • Caused by partially obstructed artery– turbulence • Listen in epigastrum and each upper quadrant • Listen in costovertebral angle(with patient seated) • Listen over aorta, iliac arteries, femoral arteries • Arterial insufficiency in legs

14. PERCUSSION • Assessment technique used to assess size and density of organs in the abdomen • Examples: used to measure size of liver or spleen

15. More on percussion • Used to identify masses • Used to identify air in stomach or in bowel • Used alone or in conjunction with palpation or to validate palpatory findings • Orient yourself to the abdomen by lightly percussing all 4 quadrants for tympany or dullness • tympany usually predominates due to gas in the bowel

16. Percussion Continued • Dullness may be present due to feces or fluid or over organs or a solid mass • Develop a specific percussion route and stick to it. • To percuss the liver or estimate its size: • in right midclavicular line, start below the umbilicus with tympany and percuss upward toward liver dullness. • Mark to indicate the liver border

17. Liver Percussion • In the right midclavicular line, percuss down from lung resonance to liver dullness. This indicates the lower border of the liver • Mark this and measure between the two lines • This is the height of the liver

18. More about percussion • Percussion provides most accurate clinical measurement of liver size as a gross measurement

19. Percussing the spleen • Where is the spleen located? • in the curve of the diaphragm just posterior to the left midaxillary line • When the spleen enlarges, it does so anteriorly, downward and medially. This will replace the tympany of the stomach and colon with dullness

20. Tricks to Assessing the Spleen • Percuss in the lowest interspace in the left anterior axillary line for tympany. • Ask the patient to take a deep breath and percuss on inspiration. • the percussion note should remain tympanic • A change to dullness suggest spenomegally • This is known as a positive splenic percussion sign

21. Another trick Percuss in several directions away from tympany or resonance to dullness outline edges a large dull area suggests splenomegally

22. Other Findings • To differentiate amongst fat, gas, tumor or ascites: • fat—tympany with scattered areas of dullness • gas—distention with tympany • tumor—dullness with tympany • ascites—fluid seeks the lowest point in the abdomen. Flanks are dull to percussion with tympanic center. There is a protuberant abdomen with bulging flanks

23. Assessing for Ascites • With patient lying supine, find tympany in center of abdomen • From center of abdomen, percuss outward in several directions to denote dullness • To test for “shifting dullness,” ask patient to turn to one side, then percuss from tympany to dullness • fluid will sink to lowest point

24. More on ascites • Assess for fluid wave • Puddle sign

25. Assessing for kidney tenderness • Find the costovertebral angle • This is the angle formed by the lower border of the 12th rib and the transverve processes of the upper lumbar vertebrae • Place left hand flat in this area on one side, hit the hand sharply with the fist of the other. Patient will admit to tenderness if present. • Repeat on the other side

26. PALPATION • Used to assess muscle tone, tenderness, fluid, organs • May be light or deep • Use pads of fingertips in light dipping motions and avoid short jabs

27. Palpation cont. • To differentiate voluntary from involuntary resistance: rectus muscle will relax with expiration. • Palpation is light or deep • Deep palpation used to define and delineate organs or abdominal masses. • Use palmar surface of fingers and feel in all four quadrants

28. Deep palpation • If masses are felt, note: location, size, shalpe, consistency, tenderness, pulsations, mobility with respiration or with hand. • If patient is obese or rigid, use 2 hands to palpate • Place one on top of other and feel with lower hand

29. The bladder • Bladder percussion is unnecessary unless there is a suspicion of urinary retention • Palpate above the symphysis • An empty bladder is not palpable

30. Palpation of the liver • Stand on patients right side • Place left hand behind patient parallel to and supporting 11-12th ribs • Patient should relax • Press your left hand forward and place your right hand on abdomen with fingertips below lower edge liver dullness • Press in and up while patient takes deep breath; if palpable, liver should come down

31. Palpation cont. • Liver hook • Kidney: not palpable in normal adult • May be able to feel lower right kidney pole in very thin person

32. The spleen • The spleen is usually not palpable • From patient’s right side, reach over and around under patient with your left hand • Place right hand below left costal margin and press in toward spleen. Ask patient to take deep breath---will feel if palpable

33. Assessing for peritoneal irritation • Ask patient to cough. Palpate lightly with one finger over area of pain produced by cough • Test for REBOUND TENDERNESS: press finger in firmly and slowly then quickly withdraw. Rebound tenderness mean the withdrawal has caused the pain--- not the pressure • Other: Psoas sign and Obturator sign, cutaneous hyperesthesia

34. Assessing the Aorta • Press firmly deep in upper abdomen slightly to left of midline. • Feel for aortic pulsations • Determine width of aorta by pressing deeply on either side of aorta • What is the normal width of the aorta? • If pulsatile mass is found, feel for femoral pulses which may be dimished.

35. This concludes the examination of the abdomen

36. Examination of the anus and rectum This information is sometimes included with the abdominal assessment and at times with assessment of the male and female genitalia. For our purposes, we are including it here

37. General Principles • Anal canal is outlet of GI tract • 3.8cm long • Merges with rectal mucosa @ anorectal junction • Sensory nerves in anal area responsible for pain due to trauma

38. Sphincters • 2 concentric layers of muscle that keep anal canal closed • Internal sphincter • under involuntary control by autonomic nervous system • External sphincter • surround internal sphincters • under voluntary control • Intersphincteric groove: palpable separation between internal and external sphincter

39. MORE THAN YOU WANT TO KNOW: • Anal columns - -folds of mucosa extend vertically from rectum and end in anorectal junction • Can be seen with scope • Each column contains and artery and vein

40. hemorrhoids • With increased venous (portal) pressure, vein can enlarge. • this is a hemorrhoid or a varicosity • External hemorrhoids occur below the anorectal junction • itch and bleed with defecation • painful and swollen with thrombosis • resolve and leave flabby skin top around • anal opening.

41. continued • Internal hemorrhoids originate above anorectal junction • covered with mucosa • may appear as red mass with pressure (valsalva)