Assessment of the Abdomen

Patricia Jackson Allen

RN, MS, PNP, FAAN
Yale University, School of Nursing
Abdominal Structures
Abdominal Structures
Abdominal Structures
Abdominal Structures
 Abdomen Mapping
 Anatomical landmarks
 Xiphoid process
 Costal margins
 Iliac crest
 Anterior superior iliac
spine
 Symphysis pubis
 Umbilicus
 Four Quadrants of Abdomen

When examining each

quadrant, remember
what organs and
structures are found
found in each quadrant
 Four Quadrants of the Abdomen
 Right Upper Quadrant
 Liver
 Pylorus valve of stomach
 Duodenum
 Right kidney and adrenal gland
 Hepatic flexure of colon
 Portions of ascending and transverse colon
 Four Quadrants of the Abdomen
 Right Lower Quadrant
 Appendix and cecum
 Ascending colon
 Bladder if distended
 Ovary
 Uterus if enlarged
 Right spermatic cord
 Right ureter
 Four Quadrants of the Abdomen
 Left Upper Quadrant
 Tip of medial lobe of liver
 Spleen
 Stomach
 Left kidney and adrenal gland
 Pancreas
 Splenic flexure of colon
 Portions of transverse and descending colon
 Four Quadrants of the Abdomen
 Left Lower Quadrant
 Sigmoid colon
 Descending colon
 Bladder if distended
 Ovary
 Uterus if enlarged
 Left spermatic cord
 Left ureter
 History
 Chief complaint / present illness
 Abdominal pain
 Indigestion
 Nausea
 Vomiting
 Diarrhea
 Constipation
 History
 Chief complaint / present illness
 Fecal incontinence
 Jaundice
 Dysuria
 Urinary frequency
 Urinary incontinence
 Hematuria, blood in stool
 Weight loss, weight gain
 History
 Symptom characteristics
 Onset and duration
 Getting better or worse
 Character or quality
 Associated symptoms
 Location, radiation
 History
 Symptom characteristics
 Factors that relieve or exacerbate symptoms
 Alterations in activities of daily living
 Others in family with similar symptoms
 Home or prescribed treatment
 Prior evaluation or treatment
 Past Medical History
 Perinatal history
 Pregnancies, abortions, miscarriages
 Birth defects
 Infant feeding problems
 Prematurity
 Short bowel syndrome
 Past Medical History
◆ Illnesses / infectious disease
– Acute GI infections – Gallbladder illness
– Hepatitis – Colitis
– PID, STI’s – Cystic fibrosis
– HIV – Food allergies / intolerance
– UTI’s – Constipation
– Diverticulitis – GERD
– Ulcers – Irritable bowel
 Past Medical History
 Immunizations
 Hepatitis B
 Hepatitis A
 Cholera
 Typhoid
 Rota virus
 Other
 Past Medical History
 Laboratory test
 Stool cultures
 Abdominal x-ray, sonograms, ultrasounds
 Urinalysis
 H. pylori tests
 Ova and parasites
 Sigmoid or colonoscopy
 Organ biopsy
 Past Medical History
 Operations / hospitalizations / ER visits
 Abdominal surgery
 Appendicitis
 Trauma to abdomen
 Births
 Blood transfusions
 Acute gastroenteritis (AGE)
 Organ inflammation (liver, pancreas, gallbladder)
 Recurrent abdominal pain
 Past Medical History
 Accidents (unintentional injury)
 Car
 Bike
 Skateboard
 Falls
 Past Medical History
 Medication use
 Antibiotics  Iron and vitamins
 Laxatives  Chronic steroid or ASA use
 Suppositories, enemas  Birth control
 Antacids  Folk remedies
 Ulcer medications
 Family History
 Infectious conditions (hepatitis, AGE)
 Constipation, irritable bowel
 Ulcers, diverticulitis, inflammatory bowel
 Gallbladder disease
 Symptoms similar to CC
 Colon cancer, ovarian cancer
 Ova and parasites
 Personal and Social History
 Nutrition
 Last menstrual period
 Sexual practices and protection
 Substance use, including caffeine, alcohol, tobacco
 Recent stress
 Weight gain or loss
 Anorexia, bulimia, dieting
 Travel outside of country
 Preparation for Abdominal
Examination
 Have child empty bladder
 Have child lie supine with hips and knees flexed
 Drape for privacy
 Tell child what you will do before you do it
 Have warm room and warm hands
 Have good light source
 Examine identified painful areas last
 Position for Abdominal
Examination

Correct Incorrect
Drape for Modesty
 Assessment of the Abdomen
 Inspection
 Auscultation
 Percussion
 Palpation
 Assessment of the Abdomen
 Inspection
 Skin
 Scars
 Striae
 Dilated veins, vein pattern
 Rashes
 Lesions
 Assessment of the Abdomen
 Inspection
 Umbilicus
 Location
 Contour
 Signs of inflammation or bulging
Contour
 Symmetrical / asymmetrical
 Flat
 Rounded
 Protuberant
 Scaphoid
 Causes of Abdominal Distention
 Obesity
 Pregnancy
 Tympanitis
 Ascites
 Feces
 Neoplasms

(Six “F’s”: Fat, Fluid, Flatus, Fetus, Fecus, Fatal growths)

 Location of Distention
 Xiphoid  Diaphragmatic hernia
 Umbilicus  Umbilical hernia
 Pubis  Pregnancy, distended bladder
 Midline  Diastasis recti
Midline Contour Variation

Diastasis Recti
 Normal Variations of
Contour with Age

 Infant-toddler
 Protuberant
 Preschool age child
 Rounded, lumbar lordosis
 School age child
 Scaphoid
 Adolescent / adult
 Varied
Infant Abdomen
Toddler / Preschooler Abdomen
School-Age Abdomen
 Assessment of the Abdomen

 Inspection
 Peristalsis
 May be seen in thin individuals or with obstructive conditions
 Pulsation
 Pulsations of descending aorta may be seen in thin individuals
 Assessment of the Abdomen
 Inspections
 Respirations
 Abdominal breathing normal until school age
 Intercostal breathing occurs with
 Respiratory distress
 Abdominal inflammation
 Pneumonia or pleural effusion may cause
 Abdominal pain
 Altered respirations
 Assessment of the Abdomen

 Auscultation
 Bowel sounds
 Vascular sounds
 Organ size, location

Warm stethoscope before use

 Assessment of the Abdomen
 Auscultation
 Increased bowel sounds
 Diarrhea
 Colic
 Malrotation
 Intussusception
 Diverticulitis
 Assessment of the Abdomen
 Auscultation
 Decreased bowel sounds
 Total obstruction
 Paralytic ileus
 Peritonitis
 Severe ascites
 Absence of bowel sounds established after 5
minutes of listening
 Assessment of the Abdomen
 Auscultation
 Scratch test for liver size
 Intensity of sound increases as you approach liver edge
Abdominal Auscultation for Bruits
Techniques for Relaxation of Children for
Percussion and Palpation

 Pacifier to encourage relaxation with sucking

 Flex knees and hips
 Distraction, support of caregiver
 Reassure procedure will not hurt
 Involve them in procedure
 Use of puppets or toys
 Assessment of the Abdomen
 Percussion
 Percussion is excellent for
assessing organ size, presence of
masses, fluid or gas.
 Tympany  stomach, bowel
 Resonance  bowel
 Dullness  liver
 Flat  thigh
 Percussion
 Tympany
 High pitch note elicited over airfilled structures, such
as viscera and stomach.
 Dull
 Short high-pitched sound with little resonance. Found
in solid or fluid filled organs adjacent to air
containing organs, i.e., liver, spleen, distended
bladder.
 Flat
 Very short, high-pitched sound produced over tissue
which contains no air, i.e., muscle, large solid mass.
 Assessment of the Abdomen
 Percuss
 4 quadrants for gas or masses
 Liver span
 Spleen size
 Costovertebral angle (CVA) tenderness
Abdominal Percussion
 Assessment of the Abdomen
 Liver percussion
 At right mid-clavicular line, start below umbilicus
and percuss upward until dullness of sound heard
 Liver usually @ right costal margin +/- 2 cm
 Size and shape of liver vary
Liver Percussion
 Assessment of the Abdomen
 Spleen Percussion
 Splenic dullness may be heard near left 10th rib
posterior to the mid-axillary line
 Usually not found unless enlarged
 Obscured by air in the colon
 Percuss at 10th intercostal space to determine
dullness with deep breath
Percussion of Spleen
Percussion of the Spleen
 Assessment of the Abdomen
 Percussion for tenderness of liver or kidneys
 Place palm of one hand over organ. Strike hand
with ulnar surface of other hand. If organ is
inflamed, this will result in pain.
 Bimanual Percussion
for Liver Inflammation
 Bimanual Percussion
for Kidney Inflammation
 Assessment of the Abdomen
 Palpation
 Light palpation
 Assessment of skin turgor
 Muscle tone
 Superficial lesions or masses
 Areas of tenderness
 Assessment of the Abdomen
 Deep palpation
 Assess for masses or enlarged organs
 Mass descriptors
 Location
 Size
 Shape
 Consistency
 Tenderness
 Pulsation
 Mobility
Light palpation Deep palpation
Structures Commonly
Palpated as Masses
 Assessment of the Abdomen
 Palpation
 Areas of cutaneous sensitivity
 Assessment of the Abdomen
 Palpation
 Liver
 Normally palpable near right costal margin, mid-
clavicular line.
 Palpate with right hand starting below umbilicus and
moving upward until liver palpable.
 Remember the liver is a superficial organ.
 Liver Palpation

Finger Tips
Side of Hand
 Assessment of the Abdomen
 Palpation
 Spleen
 Difficult to palpate unless enlarged
 Deep palpation under L costal margin at the anterior
axillary line
 Will descend with deep inspiration
 Can roll person to R side to move spleen towards midline
Spleen Palpation
Spleen Palpation
 Assessment of the Abdomen
 Palpation
 Kidneys
 Difficult to palpate unless enlarged
 With hands perpendicular to midline between rib cage
and iliac crest, press hands gently but firmly together.
 Have person take deep breath.
 May feel kidney slide between hands. Right kidney
normally lower than left kidney.
Kidney Palpation
 Assessment of the Abdomen
 Palpation
 Stool
 Firm, movable, mildly tender, elongated mass often
palpable in sigmoid colon
 Assessment of the Abdomen
 Palpation
 Bladder
 If distended, bladder is palpable midline above
symphysis pubis
 Smooth round mass, not moveable
 Assessment of the Abdomen
 Special maneuvers
 Rebound tenderness
 Psoas maneuver
 Obturator sign
 Murphy’s sign
Rebound Tenderness at McBurney Point

Sharp pain when pressure released in RLQ suggest appendicitis

 Obturator Muscle Test

Flex R leg at hip & knee. Rotate leg laterally & medially.
Pain in hypogastric region may indicate ruptured appendix
 Iliopsoas Muscle Test

Ask to raise the R leg flexing at the hip while pressing

down on lower thigh. Lower quadrant pain may indicate appendicitis.
 Murphy’s Sign

 Client complains of
sharp pain when trying
to take a deep breath
while examiner performs
deep palpation in URQ.
 Inflamed gallbladder
descends during
inspiration resulting in
pain
Abdominal Signs of Abuse
Common Abnormal
Abdominal Findings
 Hernias
 Protrusions of the peritoneum or intestine
through a weakened spot in musculature of
abdominal wall. Umbilical hernias rarely need
intervention. Inguinal and femoral hernias are
usually surgically corrected.
Umbilical Hernia
Hernia
Inguinal & Femoral Hernias
 Hernias
 Inspection
 Assess for bulges with crying or bearing down.
 Auscultation
 Assess for hums or bruits - should not be present.
May hear bowel sounds.
 Hernias
 Percussion
 Can not percuss hernia.
 Palpation
 Mass soft, nontender and retractable. Measure
opening in musculature with finger tips.
 Pyloric Stenosis

 Hypertrophy of the
pyloric valve prevents
feed from leaving the
stomach. Infant initially
feeds well but then
develops persistent
vomiting.
 Pyloric Stenosis
 Inspection
 Peristalic wave over stomach area
 Projectile vomiting
 Auscultation
 Hyperactive sounds over stomach area
 Hyperactive sounds over intestines
 Pyloric Stenosis
 Percussion
 Resonant stomach sounds. Contents expelled.
 Palpation
 An enlarged, firm, “olive shape” mass may be
palpable in RUQ. Needs to be referred to MD for
ultrasound testing and then surgery.
 Appendicitis
 Appendicitis is the most common cause of
acute surgical abdomen in childhood.
 Rare in early childhood, becoming more frequent
after age 10.
 History includes dull aching, steady peri-umbilical
pain that localizes to RLQ after 4-6 hours.
 Nausea and vomiting frequently occur but there is
no change in bowel habits. Low grade fever may
be present.
 Appendicitis
 Inspection
 Note guarding or pain with walking or coughing.
Abdominal distention may be present. Prefer
supine position with knees flexed.
 Auscultation
 Bowel sounds may be decreased or hyperactive.
Need to auscultate RLL of lungs carefully to rule
out lobar pneumonia with referred pain.
 Appendicitis
 Percussion
 Increased tenderness may make percussion too
uncomfortable to perform.
 Palpation
 Tenderness over area of inflamed appendix,
usually RLQ (McBurney point).
 Rebound tenderness localized to same area.
 Unable to palpate inflamed appendix. Rectal exam
usually finds right-sided tenderness.
Abdominal Pain
 Abdominal Pain
 Inspection
 Limitation of movement or alterations in breathing
pattern (shallow or chest breathing) are important
assessment criteria. Watch client climb on or off
the exam table
 Periumbilical pain less likely to be serious than
other locations
 Evaluate for weight loss or gain
 Abdominal Pain
 Auscultation
 Bowel sounds may be increased or decreased
 Friction rub may be heard with pleural
inflammation or peritoneal inflammation
 Percussion
 Percussion over areas of inflammation may result
in pain
 Watch facial expressions as you attempt to
distract individual. Those who watch you have
more pain.
 Abdominal Pain

 Palpation
 Palpation may identify localized or generalized pain.
 Watch facial expressions as you attempt to distract
during palpation.
 Firm but gentle palpation is best.
 Pregnancy
 Inspection
 Enlargement of lower abdomen, midline
 Enlargement of breast
 Linea nigra, increase facial pigmentation, striae
 Auscultation
 Fetal heart sounds
Pregnant Abdomen
 Pregnancy
 Percussion
 Dull mass in lower abdomen
 Displaced tympany of bowel and stomach
 Palpation
 Fetal outline
 Fundus of uterus