Abdominal assessment Flashcards
Abdominal anatomy
Divide into quadrants
- RUQ; right upper quadrant
- RLQ; right lower quadrant
- LUQ; left upper quadrant
- LLQ; left lower quadrant
Take central region and divide into three levels
- Epigastic; near the rib cage
- Umbicical; near the belly button
- Hypogatric/suprapuboic; near the pubic bone
Abdominal musculature
Parietal peritoneum - overtop of visceral
Visceral peritoneum - overlays the organs
Transversus- anterior and lateral abdominal wall and deep to the internal oblique muscle
Internal obliques
External obliques
Rectus abdominus - on top of both oblique muscle layers
Aponeurosis - plaque layer of tendon
Linea alba - top layer of muscle, joins with aponeurosis in the midline
Solid viscera
Maintain characteristic shape
- Liver
- Pancreas
- Spleen
- Adrenal glands
- Kidneys
- Ovaries
- Uterus
- Aorta
Hollow viscera
Shape depends on contents; usually not palpable unless full
- Stomach
- Gallbladder
- Small intestine
- Colon
- Bladder
Abdominal developmental considerations: infants and children
Larger liver
- At birth the liver is proportionally larger in a small body than an adult
- The lower edge of the liver may be palpable below the rib cage
Bladder is higher
- It sits up closer to the umbilicus
Abdominal wall is less muscular
- Abdominal muscle hasn’t been developed yet;
- Makes assessment easier because easier to palpate organs
Increased risk for GI illness
- Due to immune system not being fully developed until 5-6
- Contagion rate higher as they want to touch and put things in mouth
Abdominal developmental considerations: pregnancy
Nausea/vomiting
- “Morning sickness”
- More prominent in first trimester but can affect people throughout
Acid indigestion
- Elevated levels of progesterone relax smooth muscle which result in delayed smooth muscles motility
Constipation
- Delayed motility in system means more time for water to be absorbed
Diminished bowel sounds
- Difficult to hear a bowel sound; intestines displaced upwards and back
Skin changes on the abdomen
- Striae
- Linea nigra
Abdominal developmental considerations: older adults
Adipose tissue redistribution to abdomen and hips
- Adipose tissue is away from face and extremities and concentrated to abdomen and hip
Abdominal muscle relaxation
- Give abdomen a relaxed appearance
Decreased salivation
- More prone to dry mouth
Decreased gastric acid secretion
- Can affect medication and how it’s absorbed
Liver size decreased
- Liver atrophies as we age; especially after the age of 80 (important for medication metabolization)
Decreased renal functioning
- Most drugs excrete through this system
- Has implications with regards to to toxicity
Increased incidence of gallstones and colorectal cancer
Subjective assessment of abdomen
Appetite
- Anorexia; loss of appetite
Dysphagia
- Difficulty swallowing
Food intolerance
Pyrosis
- Heartburn
Abdominal pain
- Visceral, parietal, referred
Nausea/Vomiting
- Hematemesis; blood in the vomit, can occur from ulcers or abnormal enlargement of veins in esophagus
Bowel habits
- Melena stool; black and tarry stool, tells you there’s been an upper GI bled, characteristic odour
- Frank blood; bright red, very obvious blood, tells us there’s a lower GI bleed
Past Abdominal History
- Inflammatory Bowel Disease (IBD)/Irritable Bowel Syndrome (IBS)
- Colorectal cancer
- Familial adenomatous polyposis (FAP)
Medications
- Acetaminophen & ASA; can have toxic effects
- NSAIDS; can affect kidneys
Alcohol and Tobacco Use
- Risk factors for liver disease
- Cancers and GI disorders
Nutritional Assessment
- 24 hour recall
Visceral pain
- Pain from an organ
- Can be caused when an organ is contracted unusually forcefully, when its being distended or from stress
- Very difficult to localize
- Burning pain, cramping pain or aching pain
- When severe common to see marked pallor and sweating
Parietal pain
- Inflammation of the parietal perioneum
- Usually originated from a specific organ underneath
- Precisely localized, described as sharp, severs, stabbing pain
- Don’t want to more (guarding) is a classic sign
Referred pain
- Pain that’s referred to another area but that originates in abdomen
- Happens when structures are at the same spinal level
- Pain can be refereed from other sites to the abdomen (complicates the issue)
Inspection of the abdomen: contour
Expected
- Flat
- Rounded
Unexpected
- Scaphoid; likely person not eating enough
- Protuberant; too much air in abdomen cavity or too much fluid
Inspection of the abdomen: symmetry
- Expect it to be symmetrical bilaterally
- Looking for bulging, mass, or asymmetric shape
- Common unexpected findings; hernias, protrusion in the abdomen, intestine, protruding through an opening in the wall abdominal usually due to an incomplete closure
Diastasis recti
Separation of the abdominal wall as abdomen expands, most commonly happens with pregnancy
Hernias
- the abnormal exit of tissue or an organ, such as the bowel, through the wall of the cavity in which it normally resides
Umbilical hernia - creates a soft swelling or bulge near the navel. It occurs when part of the intestine protrudes through the umbilical opening in the abdominal muscles
Incisional hernia - caused by an incompletely-healed surgical wound
Inguinal hernia - occurs when tissue, such as part of the intestine, protrudes through a weak spot in the abdominal muscles
Inspection of the abdomen
Umbilicus - expected to be midline, inverted (whole ring around)
- Common during pregnancy but can also happen with ascites (with swelling from too much liquid in abdomen)
Skin - smooth, uniform in colour, might see some stretch marks, moles, any other lesions or scars?
- Also look at tugor , can be decreased die to ascites
Aorta - Assess for pulsations or movement
Peristalsis - May see waves of peristalsis
- Can see pumping of the heart sometimes from aorta
Hair distribution - loss of hair in one area; skin taught due to too much fluid in the abdomen
Demeanor - comfortable, relaxed or in a lot of pain
Auscultation of the abdomen: IAPP instead of IPPA
- Auscultate right alter we inspect
- If we percuss or palpate we alter the frequency of bowel sound
- Pre-screening; if we hear a bruit we need to stop and send to imaging
Auscultation of the abdomen: bowel sounds
- Present in all 4 quadrants?
- We don’t count sound (just present or not)
- The sound is the movement of air through the small intestine
Hypoactive
- Diminished sound
- Not a frequent as you expect
- Tells us decreased motility of GI tract
Hyperactive
- Really frequent
- Increased motility of GI tract
- Borborygmus is hyperactive bowel sound that we can hear without stethoscope
Absent sound
- Listening and we hear nothing
- Paralytic ilieus means nothing is moving in a bowel
- Common right after surgery, postOP is npo until bowel sounds present
- Can also be caused from an intestinal blockage
Auscultation of the abdomen: vascular sounds
- Listening for bruit
- Ideally hear nothing; may hear some bowel sounds
Veins we are listening to
- Aorta (mid upper)
- Renal arteries (upper lift and right)
- Iliac arteries (mid left and right near umbilicus)
- Femoral arteries (lower left and right near ASIS)
Percussion of abdomen: general tympany
- Searching for general tympany; the hollow empty stomach sound
- General areas in all 4 quadrants (not specific like respiratory)
Hepatomegaly
- Enlarged liver
- When the liver enlarges it moves farther down
- Liver span
- Scratch test
Splenomegaly
- Enlarged spleen
- When enlarged the spleen moves down towards the umbilicus
- Splenic dullness
How to perform a liver scan
- Start midclavicular at right side, area of the lung
- We percuss in intercostal spaces
- Resonant in lung tissue and the dullness when reached liver
- Below liver reach tympany sound when hitting stomach
- Liver expected to be 6-12cm in adult
- Mark areas of dullness and measure
How to perform a scratch test
- Place stethoscope midclavicaular line where we expect liver to be
- Scratch light on patient’s skin working way up from abdomen
- When hit bottom of liver it will sound very loud
- Same scratching in lung area and work down; when loud you’ve hit top of liver
How to perform a splenic dullness test
- Percuss between ribs 9-11 intercostal spaces
- Start at left side and percuss forward towards umbilicus
- Should be typmanic
- If dull it’s a positive sign
Assessing for inflammation of the kidneys
- Assessing for costoverterbral angle tenderness
- Plant hand at top of angle tap fist on top
- No sharp pain should be present; assess both sides
Palpation of the abdomen: general scan
- Looking for masses, enlargement of an organ, tenderness
- Client needs to be relaxed
- Have them bend knees up and have feet on bed, helps relaxes abdomen muscles
- Distracting conversations
- Take slow deep breaths
- Keep hand low to abdomen, avoid stabbing
Palpation of the abdomen: light palpation
- Depress in 1cm
- Forming an overall impression
- Not palpating organs, looking for masses and tenderness
Palpation of the abdomen: deep palpation
- Depress in 5-8cm
- One hand or two
- Noting location, size, consistency, mobility or organs/masses, enlargement of organs, tenderness
- Uncomfortable for client
Normally palpable abdominal structures
- Xiphoid process
- Normal liver edges
- Right kidney, lower pole
- Pulsatile aorta
- Rectus muscles, lateral boarders
- Sacral promontory
- Cecum asending colon
- Sigmoid colon
- Uterus (gravid)
- Full bladder
How to deep palpate the liver
- Two techniques
(1)
- Take hand in RUQ; stabilize with left hand
- Right hand used to palpate
- Have them take deep breaths
- Concerned if palpating quite a bit lower than expected
(2)
- Hook technique
- Go underneath, have them take a deep breath and should feel side of liver
How to deep palpate the spleen
- Spleen is palpable if very enlarged (3x)
- Normally feel nothing, if enlarged as they breath in the sleep will come down and bump you hand
- Palpating in front with hand on right side supporting
How to deep palpate the kidneys
- Almost impossible to feel
- Left not usually palpable because it sits higher
- Sometimes the right lower boarder can be felt
- Palpate from sides of abdomen
How to deep palpate the aorta
- Thumb and index finger
- Press down in epigastric region (above the umbilicus)
- Feeling for a tube
2 ½-4cm across - If wider concerned about aneurism
- But at this point we wound of already listened, heard bruit and stopped
Abdominal aortic aneurysm
- Aorta with a large abdominal aneurysm will have a build up
- Large than 3cm or >50% of normal size
- Extreme emergency, often results in death
- Why we listen before we palpate for a bruit
Blumberg’s sign: rebound tenderness
- When someone had appendicitis they also have perineoum inflammation
- Testing for that inflammation
- Press hands in 90 degrees, press down slowly then release pressure quickly
- If they have sharp pain with release that is positive sign
- Pressing on opposite side of appendix (push on left)
- If appendicitis present, sharp pain felt on right side
Iliopsoas muscle test
- Quick screen for appendicitis
- Opposing pressure on thigh
- Positive sign is shooting pain up right leg into abdomen
Murphy’s sign: inspiratory arrest
- Similar to assessing liver boarder
- If gall bladder inflamed it will be pushed into fingers
- Causing pain and inspiratory arrest
- Patient will take a sharp breath in
Ascites
- Fluid in abdominal cavity
- Can be due to cardiac issues, liver issues, abdominal cancers
- Abdomen distended
- Side areas bulged outwards
- Umbilicus often everted and points down
Fluid wave
- Client’s hand placed in midline (minimize jiggle)
- One hand on each side, give firm wrist strike
- If fluid in abdomen the fluid would form a wave through and we can feel the rebound
Shifting dullness
- Think of abdominal cavity as a Tupperware
- If we percuss down the side we hear tympany and then hit dullness when getting to organs
- If container filled with fluid, all the fluid fills the whole side
- Patient lying slightly towards you, the level of dullness rises which is a positive finding
- Looking for shifting level of DULLNESS
