ABDOMINAL

Health Assessment

Crisel Q. Costales

Department of Health and Sciences, Union Christian College

BSN-1B: Bachelor of Science in Nursing

Professor Lani C. Mueca

 ABDOMINAL

Health Assessment

Physical examination plays a key role in patient diagnosis and is an essential part of every clinical encounter of the patient with the
physician. Abdominal examination can give diagnostic clues regarding most gastrointestinal and genitourinary pathologies and may
also give insight regarding abnormalities of other organ systems.

THE PROCUDER OF THE ABDOMINAL

Equipments
Stethoscope
Preparation
1. Wash hands thoroughly with soap and water. An alcohol-
based sanitizer can also be used. It is essential for the examiner
to ensure that his or her hands are dry and warm before
starting the examination.
2. Identify the patient.

3. Briefly explain the reason for and the steps of the examination
and take consent from the patient.
4. Inquire if the patient has any pain.

5. Position the patient. The patient is initially positioned

at 45 degrees for comfort but a supine position is necessary for
palpation of the abdomen. Keeping a pillow under the patient’s
 head or knees can be considered.
6. The ideal exposure is from the nipples to the knees, but
this is sometimes not practically possible. During most clinical
examinations, the exposure is from the nipples to the lower
abdomen.
Health Assessment
General Inspection:

7. Begin with the general inspection of the patient and then

proceed to the abdominal area. This should be performed at
the foot end of the bed. The general inspection can give
multiple clues regarding the diagnosis of the patient, for
example, yellowish discoloration of the skin (jaundice)
indicates a possible hepatic abnormality.
8. It is important to note any medical equipment for monitoring
and/or treatment attached to the patient or present in the bed
space. These may include catheters, pulse oximeter, oxygen
mask and tubing, nasogastric tube, central lines, and total
parenteral nutrition lines.
Inspection
9. The general contour of the entire abdominal wall is observed.
The contour should be checked carefully for distention and
note made as to whether any distention is generalized or
 localized to a portion of the abdomen. Similarly, the flanks
should be checked for any bulging.
10. The skin of the abdomen should also be checked carefully for
engorged veins in the abdominal wall and the direction of
blood flow in these veins. This is performed by placing the tips
of the index fingers together, compressing a visible vein.
11. The abdomen should be inspected for masses. This should be
performed from several angles. It is important to differentiate
abdominal wall from intra-abdominal masses.
Palpation
12. The ideal position for abdominal examination is to sit or kneel
on the right side of the patient with the hand and forearm in
the same horizontal plane as the patient’s abdomen. There are
three stages of palpation that include the superficial or light
palpation, deep palpation, and organ palpation and should be
performed in the same order.
13. The examiner should begin with superficial or light palpation
from the area furthest from the point of maximal pain and
move systematically through the nine regions of the abdomen.
If no pain is present, any starting point can be chosen.
14. Deep palpation should be performed in the same position of
the hand and forearm relative to the patient’s abdomen but
with the application of firm and steady pressure. It is important
 to press slowly as pressing too fast may trap a gas pocket
within the intestinal lumen and distend the wall resulting in
false-positive tenderness.
15. During palpation, tenderness should be noted which may
present as guarding. This may be a voluntary process, in which
the patient voluntarily tightens the abdominal muscles to
protect a deeper inflamed structure, or an involuntary process,
where the intra-abdominal pathology has progressed to cause
rigidity of the abdominal muscles
16. In the right lower quadrant, tenderness over McBurney's point If tenderness is appreciated at the McBurney’s point, the following
implies possible appendicitis, inflammation of the ileocolic maneuvers to identify possible appendicitis should be performed:
area that may be due to Crohn's disease or an infection with  Rovsing's sign: While standing on the patient's right side,
bacteria that have a predilection for the ileocecal area such as gradually perform deep palpation of the left lower quadrant.
Bacillus cereus and Yersinia enterocolitica. Increased pain on the right suggests right-sided peritoneal
irritation
 Psoas sign: Place your hand just above the patient's right knee
and ask the patient to push up against your hand. This results
in contraction of the psoas muscle which causes pain if there is
an underlying inflamed appendix.
 Obturator sign: This is performed by flexing the patient's right
thigh at the hip with the knee flexed and rotating internally.
Increased pain at the right lower quadrant suggests
inflammation of the internal obturator muscle from overlying
 appendicitis or an abscess.
17. Palpate the periumbilical area for any defect, mass, or an A mass palpated in the suprapubic area may be due to a uterine
umbilical hernia. The patient can be asked to cough or bear pathology such as uterine fibroids or uterine cancer in females or
down to feel for any protruding mass. bladder mass or distension in both males and females.
18. Proceed to palpation of the abdominal organs and to palpate
the liver, the examiner must place the palpating hand below
the right lower rib margin and have the patient exhale and then
inhale. With mild pressure, the liver margin may be felt under
the hand as a gentle wave. It is important to feel for any
nodularity or tenderness. For palpation of the gallbladder, it is
recommended that the examiner gently place the palpating
hand below the right lower rib margin at the midclavicular line
and ask the patient to exhale as much as possible.
Percussion
19. The percussion of the Castell's point (the most inferior
interspace on the left anterior axillary line) as the patient takes
a deep inspiration, may be helpful. A percussion note that
changes from tympanitic to dull as the patient takes a deep
breath suggests splenomegaly, with an 82% sensitivity and an
83% specificity. Splenomegaly occurs in trauma with
hematoma formation, portal hypertension, hematologic
malignancies, infection such as HIV and Ebstein-Barr virus,
and splenic infarct
 20. Percussion is necessary to assess the size of the liver, Shifting dullness, present in ascites, should be demonstrated by
percussion downward from the lung to the liver and then the percussing from the midline to the flank till the note changes from
bowel, the examiner may be able to demonstrate the change in dull to resonant and then having the patient roll over on their side
percussion note from resonant to dull and then tympanitic. towards the examiner and wait for ten seconds
Auscultation
21. The diaphragm of the stethoscope should be placed on the Normal bowel sounds are low-pitched and gurgling, and the rate is
right side of the umbilicus to listen to the bowel sounds, and normally 2-5/min. Absent bowel sounds may indicate paralytic ileus
their rate should be calculated after listening for at least two and hyperactive rushes (borborygmi) are usually present in small
minutes. bowel obstruction and sometimes may be auscultated in lactose
intolerance
22. The diaphragm should be placed above the umbilicus to listen These clinical findings must be correlated with the remaining physical
for an aortic bruit and then moved 2 cm above and lateral to examination and history to formulate a preliminary diagnosis. If there
the umbilicus to listen for a renal bruit. is a clinical suspicion of delayed gastric emptying, a maneuver, that is
sometimes uncomfortable for the patient, may be performed. The
examiner should place the stethoscope on the abdomen and hold the
patient at the hips and shake him from side to side. If splashing
sounds, called the ‘succussion splash’ are audible, the test is positive.
Digital Rectal Examination
23. The abdominal examination ends with the digital rectal Tenderness or bogginess suggests prostatitis and nodules may suggest
examination. The examiner should place his or her lubricated, cancer. After the finger is removed it should be inspected for signs of
gloved finger against the patient’s rectal sphincter muscle to active bleeding or melena. Perform a Guaiac test if bleeding is
dilate the sphincter and slowly slide it into the rectum suspected. Examination of the external genitalia should also be
palpating for hemorrhoids, fissures, or foreign bodies. The performed.
 prostate for size and firmness should be assessed.
24. Document findings in the client record using printed or
electronic forms or checklists supplemented by narrative notes
when appropriate

Clinical Signifance

Abdominal examination is an essential part of all routine physical examinations as well as a key step in the evaluation of any
abdominal pathology. After taking a thorough history, a detailed physical examination is mandatory, if no time constraints are present.
Even in emergencies, a brief abdominal examination can help decide further management. A well-performed abdominal examination
can give multiple clues to the final diagnosis and may greatly decrease the need for unnecessary laboratory and radiological
investigations. In situations, when the diagnosis is unclear, a detailed abdominal examination can help narrow down the diagnosis and
help order focused investigations. This helps to decrease the physician’s time, energy, and resources and subjects the patient to
decreased mental stress and hospital costs.

THE NORMAL AND ABNORMAL FINDINGS IN ABDOMINAL

NORMAL ABNORMAL
Precussion Sounds Abdominal Distention:
Resonance: Heard over lung tissue Obesity
Tympany: heard over most portions of the abdominal cavity Air or gas
Dullness: heard over solid organs (eg, liver) and muscles Ascites
 Ovarian cyst
Pregnancy
Feces
Tumor
Auscultation Palpation on Enlarged Organs:
Normal bowel sound Enlarged liver
Enlarged nodular liver
Enlarged gallbladder
Enlarged spleen
Enlarged kidney
Aortic aneurysm
Inspection Appearance of the Skin in Abdomen
Contour Abnormal venous patterns
- Normal ranges from flat Abnormal discoloration
Symmetry Umbilicus is sunken
- Should be symmetric, note bulging and masses or
symmilatry
Umbilicus
- Normal is midline, inverted and no discoloration
Skin
- Surface normally smooth and even color.

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