Assessment of the Abdomen
I. Health History
A. Current Status
1. Describe chief complaint
2. Pain
3. Ability to walk upright
4. Nutritional Assessment
a. 24 hour recall
b. Food preferences and dislikes
c. Cultural and religious values
d. Access to food
e. Eating behaviors
f. Appetite changes
5. Indigestion
a. Fullness
b. Heartburn
c. Discomfort
d. Excessive belching
e. Flatulence
f. Loss of appetite
g. Pain
6. Heartburn - usually substernal
a. Body positions
b. Food irritants
c. Time of day
7. Nausea
8. Vomiting
a. Appearance of emesis/odor
b. Hematemesis
9. Stool
a. Diarrhea - watery or loose stool
b. Tenesmus - cramping pain with strained, ineffectual evacuation
c. Steatorrhea - frothy, greasy, and foul-smelling stool w/undigested fat
d. Melaena - black, tarry stool
e. Bloody red stool
f. Occult blood
g. Constipation
h. Ability to pass flatus
10. Alcohol intake
11. Fever
12. Difficulty breathing
13. Swelling of lymph nodes in neck, axilla, and groin
B. Past Health Status
1. Have you had any problems with your mouth, throat, abdomen, or rectum that have lasted for a long time?
2. Have you had any nerve problems, such as weakness or numbness in your hands and fingers?
3. Have you ever had surgery on your mouth, throat, abdomen, or rectum?
4. Do you have any allergies such as to milk products?
5. Do you use laxatives or enemas? If so, how often?
6. Do you take any prescription or over-the-counter medications? If so, which drugs and at what dosages?
C. Family Health Status
1. Has anyone in your family had colorectal cancer or polyps?
2. Has anyone in your family had colitis?
II. Physical Examination of the Abdomen
A. General Approach
1. Patient must be warm and relaxed.
2. Good lighting.
3. Full exposure of abdomen from xyphoid process to groin.
4. Patient should not have full bladder.
5. Position in supine position with pillow under head and knees.
6. Arms should be held across chest or be at sides.
7. Have warm hands and a warm stethoscope.
8. Avoid quick, unexpected movements.
9. Distract the patient with questions.
10. Monitor your examination by watching patient's face.
B. Inspection of the Abdomen
1. Contour and Symmetry
a. Flat
b. Scaphoid - seen in school-aged children and wasting diseases
c. Round - pot belly; normal in infants and toddlers
d. Protuberant
e. Distended
2. Scars
a. Location
b. Length
c. Color
3. Striae - prolonged stretching of the skin; seen in ascites, obesity, tumor, pregnancy, and Cushing's Syndrome
a. Color: white/silver red/pink/blue purple
4. Rashes and Lesions
a. Spider nevi (cutaneous angiomas)
5. Umbilicus
a. Contour
b. Location
c. Signs of hernia - lifting head or coughing - considered normal in white skinned children until age 2 and in black skinned children until age 7
d. Cullen's sign - bluish discoloration - suggests intraperitoneal hemorrhage
6. Enlarged organs
a. Assess during deep breath
b. Differentiate between masses in the abdominal wall and intra-abdominal masses by having patient voluntarily tense abdominal muscles.
7. Masses - note size and location during deep inspiration
8. Peristalsis
a. Thin individuals
b. Intestinal obstruction
9. Dilated veins - seen with increased collateral circulation
10. Distribution of Pubic Hair (Escutcheon)
a. Female distribution - triangle with base above the symphysis
b. Male distribution - diamond with upper vertex extending as high as the umbilicus
11. Turner's sign - blue discoloration of the flanks - indicates gastrointestinal hemorrhage. There is extravasation of blood from intra-abdominal organs to extraperitoneal sites (for example, hemorrhagic pancreatitis).
C. Auscultation of the Abdomen
You must auscultate before you percuss or palpate abdomen because these maneuvers may alter the frequency of bowel sounds. Enhanced peristaltic sounds may mask other abnormal abdominal sounds such as bruits and friction rubs.
1. Bowel sounds - listen and note frequency and character (normal sounds consist of clicks and gurgles and occur 5 to 34 per minute).
a. Frequency
b. Intensity
c. Location
d. Pitch
e. Pattern
1. Absence of bowel sound - established only after 5 minutes of continuous listening. Caused by an immobile bowel of adynamic ileus (peritonitis, severe hypokalemia, complete obstruction, paralytic ileus, gangrene). A full bladder can obscure sounds.
2. Sluggish (hypoactive) bowel sounds - 3 to 5 per minute; seen with decreased bowel motility.
3. Hyperactive bowel sounds - short but frequent peristaltic sounds. greater than 34 sounds per minute. Caused by anxiety, infectious diarrhea, irritation of intestinal mucosa from blood, or gastroenteritis.
4. High-pitched tinkling sounds and rushes - hyperperistalsis also occurs during intestinal obstruction as the intestine tries to push contents through obstructed area. Usually accompanied by cramping pain.
5. Borborygmi
2. Vascular Sounds
a. Auscultation of Bruits
|
Location |
Indication |
|
Over abdominal aorta |
Atherosclerosis Aneurysm Aortic compression by a tumor |
|
Renal arteries |
Renal artery stenosis (check for hypertension) |
|
Right upper quadrant |
Vascular tumor of the liver (Hepatoma, Hemangioma) |
|
Iliac arteries |
Atherosclerosis |
|
Femoral arteries |
Atherosclerosis |
b. Auscultation of Friction Rubs - grating sounds that are heard in association with respirations as roughened serous membranes rub over each other.
c. Venous Hum - auscultate over epigastric and umbilical area. Listen for a soft low pitched continuous sound. Occurs over areas with increased collateral circulation between portal and systemic venous systems.
D. Percussion of the Abdomen
Percussion of the abdomen helps assess for intestinal distention, free fluid, solid masses, hepatomegaly, and splenomegaly. It is contraindicated in clients with AAA and organ transplants.
1. Percuss in all 9 sections to assess for tympany and dullness
a. Tympany - children's abdomens are usually more tympanic than adults (swallowed air)
b. Dullness
2. Assess for gastric tympany
3. Assess for liver dullness
4. Assess for suprapubic dullness
5. Assess for splenic dullness
a. 10th ICS posterior to mid-axillary line
6. Percuss the lower and upper border of the liver at the midclavicular and midsternal lines
a. Normal limits: 6-12 cm at midclavicular line
4.4-8.2 cm at midsternal line
Children: 5 yrs - 7 cm
12 yrs - 9 cm
b. Hepatic enlargement suggests:
1. Downward displacement of the liver by emphysematous lung
2. Mass adjacent to the liver
3. Hepatitis
c. Absence of liver dullness suggests:
1. Perforation of hollow intestinal organ/air in abdominal cavity
2. Small, atrophic cirrhotic liver
7. Percuss the flanks for shifting dullness
a. Ascites
E. Palpation of the abdomen
1. Light Palpation - use a light, gently dipping motion to palpate for superficial organs, masses, areas of tenderness, and increased resistance (1-2 cm)
a. Normal consistency
b. Guarding
c. Tenderness
d. Special considerations
1. Ticklishness
2. Flex knees
3. Palpate areas of tenderness last
2. Deep Palpation - 2-handed technique - hand moves with expiration and rests with inspiration (4 cm)
a. Masses (neoplasms, cysts, aneurysms, feces in bowel)
b. Tenderness
c. Rigidity
1. Voluntary tightening - fear or nervousness
2. Involuntary rigidity - inflammation of the peritoneum
3. Assessing Abdominal Pain
a. Visceral pain - arises from within the abdominal organ. dull pain, poorly localized (intestinal obstruction, pancreatic tumor)
b. Parietal (somatic) pain - caused by inflammation of structure that is innervated by a somatic sensory nerve. Pain is sharp and well localized (peritonitis, ruptured appendix)
c. McBurney Point - a point of specialized tenderness in acute appendicitis between the umbilicus and the right anterior superior iliac spine. Appendicitis pain starts in the umbilical area and progresses down to the right lower quadrant.
4. Rebound Tenderness - occurs when parietal peritoneum becomes inflamed
a. Press over region far away from the tender area and release pressure suddenly. Pain will occur in area of disease.
b. Apply gentle pressure over tender area and have patient cough.
5. Palpation for Splenic Enlargement - seen in hyperplasia, congestion, neoplasms, fatty infiltration, systemic infections, and chronic anemia.
a. Stand at patient's right
b. Place a supporting left hand under patient's left costovertebral angle and exert pressure to push spleen anteriorly
c. At the same time, slide the fingers of your right hand gently upward beneath the patient's left anterior costal margin
d. Ask patient to take a deep breath
e. A palpable spleen is always considered enlarged. A spleen must be enlarged 3-5 times in order to be palpable.
f. If you suspect the spleen is enlarged but you cannot feel it while patient is in the supine position, repeat the procedure while the patient is in the right lateral decubitus position.
6. Palpate over the suprapubic region for a large distended bladder. A bladder can distend as far as the umbilicus.
7. Palpate for Hepatic Enlargement
Palpate the Liver - support posterior 11th and 12th rib, gently pressing upward with left hand. Place right hand to the side of the rectus muscle and press upward. Ask the patient to take a deep breath and feel the lower border of the descending liver as it strikes the fingertips. A hooking technique may also be used.
a. A palpable liver may be caused by:
1. Abnormally large liver (neoplasms, hepatitis, early cirrhosis)
2. A liver that is pushed downward by a low diaphragm
3. A congenitally large right lobe
b. Describe edge of the liver:
1. Nodular - neoplasm
2. Soft - very hard liver indicated cirrhosis
3. Smooth - normal
4. Tender - inflammation of the liver
8. Palpation for aortic aneurysms
a. In a thin individual the normal aorta may be felt as a pulsatile structure midline in the abdomen
b. In an aneurysm the aorta is a sausage-like enlargement that has a strong pulsation and is expansible. The pulsations will displace the examining fingers laterally. Also pain in the abdomen or back may be present.
9. Vertebral tenderness - palpate with one finger into the soft tissues of the costovertebral angle (between the spine and the 12th rib). Tenderness on palpation suggests inflammation of the kidney.
10. Palpation of the kidneys
a. Place one hand posteriorly beneath the costal margin and press directly upward.
b. Palpate the kidney by pressing deeply below the costal margin at the midclavicular line as the patient takes a deep breath. You can try to capture the kidney between your 2 hands.
c. Palpate the right kidney while standing on patient's right side and palpate left kidney by standing on the patient's left side.
d. Palpation of kidneys is similar to palpating the liver and spleen except the hand is pressed more deeply into the abdomen. A right kidney may be palpable. A normal left kidney is rarely palpable.
e. Renal enlargement occurs in infection, tumor, and polycystic kidneys.
f. Contraindication to palpating kidneys
1. Renal Transplant Patients
2. Embryoma (Wilm's Tumor) - a malignant tumor in young children (seeding of a tumor).
11. Palpation of inguinal and femoral lymph nodes. Found above and below inguinal ligament. The inguinal lymph nodes are frequently enlarged from superficial infections of toes and feet. They are also enlarged in systematic viral infections, fungal parasitic or protozoal infections or in lymphoma or leukemia.
12. Palpation of femoral pulses. Also look for femoral hernia (more common in women).
13. Fluid Wave Test in Ascites
a. Use 2 people for this test. Assistant will place hand midline down abdomen.
b. Tap one flank and feel opposite flank for a delayed impulse transmitted throughout the fluid. Seen with greater than 500cc of ascitic fluid.
14. Hepatojugular reflux
This is an early sign of venous constriction that occurs before increase in venous pressure is demonstrable by other means.
a. Lower the patient's head until the venous pulsation in jugular vein is just visible above the clavicles.
b. Remind the patient to breathe at a normal rate and depth.
c. Place hand in right upper quadrant of the abdomen and press firmly upward under the costal margin.
d. If venous constriction is present, displacement of this small amount of blood from the liver will cause a visible rise in the column of blood in the jugular veins. Seen in early CHF and cardiac tamponade.
15. Special Maneuvers