Chapter 22-Abdomen

Question 1

Surface landmarks

Answer 1

-borders of abdominal cavity
-abdominal muscles

Question 2

Internal anatomy (viscera)

Answer 2

solid viscera
-liver
-pancreas
-spleen
-adrenal glands
-kidneys
-ovaries
-uterus

Question 3

internal anatomy (viscera) cont.

Answer 3

internal anatomy
-hollow viscera, shape of hollow viscera depends on content
-stomach
-gallbladder
-small intestine
-colon
-bladder

Question 4

structure & function

Answer 4

-divide the abdomen into 4 quadrants
-systematic approach starting with right lower quadrant
-proceed in a clockwise direction
-inspection followed by auscultation (bowel sounds) then percussion and palpation

Question 5

abdominal wall divided into 4 quadrants

Answer 5

-right upper
-left upper
-right lower
-left lower

Question 6

two methods

Answer 6

-quadrants
-regions

Question 7

Subjective data-health history questions

Answer 7

-appetite, anorexia…why?
-dysphagia…why?
-food intolerance, e.g. cultural, lactose intolerance, allergies
-abdominal pain, apply complete pain assessment criteria, is there a history of gastrointestinal problems?
-nausea/vomiting, characteristics? frequency?

Question 8

subjective data-health history questions (cont)

Answer 8

-bowel habits, what is true constipation versus hard, small stool and straining. what may be causing problems with constipation? ie. activity, diet, medications, inability to toilet
-bowel habits…why?
-abdominal history…is there one?
-medications, what is their effect on abdominal assessment?
-nutritional assessment e.g. weight, diet, dairy, lab results

Question 9

conducting the physical exam

Answer 9

-provide for privacy, minimal exposure
-enhance relaxation
-determine if there are any areas of tenderness/pain before proceeding
-measure and document thoroughly significant findings i.e. surgical scars, presence of stomas for example
-warm stethoscope

Question 10

abdominal assessment of the aging adult

Answer 10

-abdominal muscles relax
-fat accumulation is common
-decrease saliva, decreased sense of taste, increase use of salt and sugar
-delayed esophageal emptying, increases risk of aspiration
-decreased gastric acid secretion, pernicious anemia, ca+ absorption may be problematic
-increased incidence of gallstones
-decrease in liver size after 80, but should still function normally although metabolism of drugs will be impaired due to decrease blood flow to the liver

Question 11

objective data-preparation

Answer 11

-adequate lighting
-expose abdomen so that it is fully visible, drape genitalia and female breasts
-position for comfort to enhance abdominal wall relaxation
-empty bladder prior to examination with specimen saved if needed
-warm stethoscope and examine areas identified as painful last to prevent guarding
-auscultate prior to palpation and percussion
-use distraction to keep patient relaxed and facilitate muscle relaxation

Question 12

objective data-equipment

Answer 12

-stethoscope, small centimeter ruler, and skin-marking pen
-alcohol wipe to clean endpiece

Question 13

Objective data-the physical exam..inspection

Answer 13

first step…inspect the abdomen, patient with arms at their side, relaxed position
-contour, e.g. flat, rounded
-symmetry,…compare sides
-umbilicus…characteristics?
-skin assess of the abdomen is now incorporated here
-pulsation or movement present, where? why?
-hair distribution

Question 14

contour

Answer 14

-flat
-scaphoid
-rounded
-protuberant

Question 15

assessing and interpreting abdominal distention…

Answer 15

-bulges and masses
-presence of a hernia
-obesity
-air or gas
-ascites
-presence of feces

Question 16

auscultate bowel and vascular sounds

Answer 16

this is done because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds
-use diaphragm end piece because bowel sounds are relatively high pitched
-hold stethoscope lightly against skin; pushing too hard may stimulate more bowel sounds
-begin RLQ at ileocecal valve area because bowel sounds are normally always present here

Question 17

Auscultation

Answer 17

auscultation for bowel sounds, listening for the movement of air and fluid through the small intestine
-follow correct sequence, what is it?
-use diaphragm of stethoscope, hold lightly
-note character and frequency of sounds
-normal sound is high pitched, gurgling, cascading, irregular 5-30 per minute
-hypoactive < 5 per minute
-hyperactive > 30 per minute
-absent must listen for 5 minutes to make this determination

Question 18

more auscultation

Answer 18

-auscultation for vascular sounds
-follow correct sequence and landmarking guidelines, what are they?
-use bell of stethoscope to listen to low-pitched vascular sounds
-normal NOT to hear anything, may hear heart beat especially when listening for a bruit in the abdominal aorta area
-bruit is an abnormal vascular sound caused by stenosis of an artery that results in turbulent blood flow, whooshing sound, or by dilated, tortuous vessels (if loud bruit do not palpate)

Question 19

percussion

Answer 19

-use proper indirect percussion technique, may use reflex hammer as a novice to elicit more sound
-follow proper sequence and use a zigzag pattern
-assessing for density, size, and location of organs
-screening for presence of abnormal fluid or masses
-tympany should be the dominate sound produced (over air filled areas-i.e. intestines)
-expect a dull sound over organs
-expect a flat sound over bone

Question 20

abnormal findings-abnormalities on palpation of enlarged organs

Answer 20

-enlarged liver
-enlarged nodular liver
-enlarged gallbladder
-enlarged spleen
-enlarged kidney
-aortic aneurysm

Question 21

palpation

Answer 21

-use proper technique in a zigzag pattern, lift fingers, do not drag them, using a gentle rotation movement, using four fingers close together
-ask if any tender or painful areas
-if so palpate them last
-start with light palpation (depress skin 1 cm)
-follow with deep palpation (depress skin 5-8 cm)

Question 22

more palpation

Answer 22

usual technique for liver palpation
-have patient bend knees to relax
-your hand position should be parallel to the abdomen
-ask patient to breathe slowly
-place your hand on the back of the patient between the 11th and 12th rib and push up
-at the midclavicular line with your hand parallel to the abdomen push down deeply under the right costal margin while asking the patient to take in a deep breath
-you may feel the liver bump up against your hand during inhalation

Question 23

special procedures for advanced practice

Answer 23

-rebound tenderness (blumberg’s sign) for peritoneal inflammation, associated with appendicitis
-note: involuntary rigidity is a constant board-like hardness of muscles and occurs with acute inflammation of the peritoneum
-inspiratory arrest (Murphy’s sign) test for inflamed gallbladder

Question 24

special procedures for advanced practice (cont)

Answer 24

tests for suspected appendicitis:
-lliopsoas muscle test
-obturator muscle test

-spleen palpation
-kidney palpation
-costovertebral tenderness-tapping over the flank (over kidney) can indicate kidney infection and/or stone

Question 25

common reasons for abdominal distention

Answer 25

-obesity
-air or gas
-ascites
-ovarian cyst
-pregnancy
-feces
-tumor

Question 26

differentiating hernias

Answer 26

-umbilical hernia
-epigastric hernia
-incisional hernia

Question 27

concept of referred pain

Answer 27

location of pain may not be directly over the involved organ
-liver: RUQ
-esophagus: behind lower sternum
-ulcer: shoulder
-gallbladder: RUQ
-appendix: RLQ
-pancreas: mid epigastric pain that radiates
-kidney: flank or lower abdominal pain
-small intestine: diffuse, generalized abdominal
-colon: colicky pain & bloating

Question 28

summary checklist: abdomen examination

Answer 28

-inspection
-contour, symmetry, umbilicus, skin, pulsation or movement, hair distribution & demeanor

-auscultation
-bowel sounds; note any vascular sounds

-percussion
-all 4 quadrants and borders of liver & spleen

-palpation
-light and deep palpation in all 4 quadrants, & palpate for liver and spleen