- Ask the client to empty the bladder before the examination

- Instruct the client to remove clothes and to put on a gown.

- Help the client to lie supine with the arms folded across the
chest or resting by the sides
1. Gather equipment (pillow/towel, centimeter ruler, stethoscope,
marking pen).
2. Explain procedure to client.
3.
3. Ask client to put on a gown.
Abdomen
1. Inspect the skin, noting color, vascularity, striae or stretch
mark, scars and assess for the lesions and rashes
Inspect the skin noting color
Normal Findings: Abdominal skin may be paler than the general
skin tone because this skin is so seldom exposed to the natural
elements.
Abnormal Findings:
- Purple discoloration at the flanks
- yellow hue of jaundice
- Pale, taut skin may be seen with ascites
- Redness may indicate inflammation.
- Bruises or areas of local discoloration
Note for vascularity
Normal Findings: Scattered fine veins may be visible.
Abnormal Findings: Dilated veins
- Dilated surface arterioles and capillaries with a
 central star (spider angioma)
OLDER ADULT CONSIDERATIONS
Dilated superficial capillaries without a pattern may be seen in
older clients.
Note of striae or stretch mark
Normal Findings: New striae are pink or bluish in color; old striae
are silvery, white, linear, and uneven stretch marks from past
pregnancies or weight gain.
Abnormal Findings:
-Dark bluish-pink striae are associated with Cushing’s syndrome.
- Striae may also be caused by ascites, which stretches the skin.
Note of scars (keloid)( Saan nakuha, measured by tape measure,
where is the location)
Normal Findings: Pale, smooth, minimally raised old scars may be
seen.
Abnormal Findings:
-Non healing wounds, redness, inflammation.
- Deep, irregular scars may result from burns.

Assess of lesions and rashes (wear gloves to inspect lesions).

Normal Findings: Abdomen is free of lesions or rashes.
- Flat or raised brown moles
Abnormal Findings:
- Changes in moles including size, color, and border symmetry.
- Bleeding moles or petechiae (reddish or purple lesions) may also
be abnormal
2. Inspect the umbilicus, noting color, location, and contour.
 Note the color
Normal Findings: Umbilical skin tones are similar to
surrounding abdominal skin tones or even pinkish.
Abnormal Findings:
- Cullen’s sign: A bluish or purple discoloration around the
umbilicus (periumbilical ecchymosis)
- Grey-Turner’s sign: bluish
of purplish discoloration on the abdominal flanks.
Observe the umbilical location
Nomal Findings: Umbilicus is midline at lateral line.
Abnormal Findings: A deviated umbilicus may be caused by
pressure from a mass, enlarged organs, hernia, fluid, or scar
tissue.

Observe the contour of umbilical

Normal Findings: It is recessed (inverted) or protruding no
more than 0.5 cm, and is round or conical.
Abnormal Findings:
- An everted umbilicus is seen with abdominal distention
- An enlarged, everted umbilicus suggests umbilical hernia
3. Inspect the contour of the abdomen.
Abdominal Detention
1. Sitting at the client’s side, look across the abdomen at a
level slightly higher than the client’s abdomen.
2. Inspect the area between
the lower ribs and pubic bone.
3. Measure abdominal girth
 Normal Findings: -Abdomen is flat, rounded, or scaphoid
Abdomen should be evenly rounded.
Abnormal Findings: A generalized protuberant or distended
abdomen
-Distention below the umbilicus
- Distention of the upper abdomen
7 F’s Fat, Fluid, Flatus, feces, fetus, fatal growth, fibroid
tumor
4. Inspect the symmetry of the abdomen.
Normal Finding: Abdomen is symmetric.
Abnormal Findings: Asymmetry may be seen with organ
enlargement, large masses, hernia, diastasis recti, or bowel
obstruction

5. Inspect abdominal movement, noting respiratory movement,

aortic pulsations, and/or peristaltic waves.
Observe respiratory movement
Normal Findings: Abdominal respiratory movement may be
seen, especially in male clients.

Abnormal Findings: Diminished abdominal respiration or

change to thoracic breathing in male clients may reflect
peritoneal irritation.
Appendicitis, pancreatitis
Observe aortic pulsations (lower quadrant)
Normal Findings: A slight pulsation of the abdominal aorta,
which is visible in the epigastrium, extends full length in thin
people.
 Abdominal Findings: Vigorous, wide, exaggerated pulsations
may be seen with abdominal aortic aneurysm
Observe peristaltic waves
Normal Findings: Peristaltic waves are not seen, although
they may be visible in very thin people as slight ripples on the
abdominal wall.
Abnormal Findings: Peristaltic waves are increased and
progress in a ripple-like fashion from the LUQ to the RLQ
with intestinal obstruction (especially small intestine).

6. Auscultate for bowel sounds, noting intensity, pitch, and

frequency.
- Use the diaphragm of the stethoscope and make sure
that it is warm before you place it on the client’s abdomen.
- Apply light pressure or simply rest the stethoscope
on a tender abdomen.
- Begin in the RLQ and proceed clockwise, covering
all quadrants.
- Listen for at least 5 minutes before determining that
no bowel sounds are present and that the bowels are silent.
- Confirm bowel sounds in each quadrant. Listen for
up to 5 minutes (minimum of 1 minute per quadrant) to
confirm the absence of bowel sounds.
Normal Findings:
A series of intermittent, soft clicks and gurgles are heard at a rate of
5–30 per minute.
Abnormal Findings:
- Hyperactive” bowel sounds that are rushing, tinkling, and high
pitched
- Hypoactive” bowel sounds indicate diminished bowel motility.
- Decreased or absent bowel sounds
- Absent bowel sounds may be associated with peritonitis or
paralytic ileus. High-pitched tinkling and rushes of high-pitched
sounds with abdominal cramping usually indicate obstruction

7. Auscultate for vascular sounds and friction rubs. (Bell of

stethoscope to listen for bruits-vascular mermer)
Auscultate for vascular sounds
- Use the bell of the stethoscope to listen for bruits (low-pitched,
murmur-like sound) over the abdominal aorta and renal, iliac,
and femoral arteries

Normal Findings: Bruits are not normally heard over abdominal

aorta or renal, iliac, or femoral arteries. However, bruits confined to
systole may be normal in some clients depending on other
differentiating factors.
Abnormal Findings: A bruit with both systolic and diastolic
components occurs when blood flow in an artery is turbulent or
obstructed.
Auscultate for friction rubs over the liver and spleen.
- Listen over the right and left lower rib cage with the
diaphragm of the stethoscope.

Normal Findings: No friction rub over liver or spleen is present.

Abnormal Findings:
- Friction rubs are rare.
- A friction rub heard over the lower right costal area
- A rub heard at the anterior axillary line in the lower
left costal area
8. Percuss the abdomen for tone.
-Lightly and systematically percuss all quadrants
Normal Findings:
- Generalized tympany predominates over the abdomen
because of air in the stomach and intestines.
- Dullness is heard over the liver and spleen.
-Dullness may also be elicited over a nonevacuated descending
colon
Abnormal Findings:
-Accentuated tympany or hyperresonance is heard over a
gaseous distended abdomen.
- An enlarged area of dullness is heard over an
enlarged liver or spleen.
-Abnormal dullness is heard over a distended bladder,
large masses, or ascites.
 9. Percuss the span or height of the liver by determining its lower
and upper boarders.

A. To assess the lower border, begin in the RLQ at the mid-

clavicular line (MCL) and percuss upward. Note the
change from tympany to dullness. Mark this point: It is the
lower border of liver dullness. To assess the descent of the
liver, ask the client to take a deep breath and hold; then
repeat the procedure. Remind the client to exhale after
percussing.

B. To assess the upper border, percuss over the upper right

chest at the MCL and percuss downward, noting the
change from lung resonance to liver dullness. Mark this
point: It is the upper border of liver dullness.

Measure the distance between the two

marks: this is the span of the liver

Repeat percussion of the liver at the midsternal line (MSL).

Normal Findings: The lower border of liver dullness is located at
the costal margin to 1 to 2 cm below
-On deep inspiration, the lower border of liver dullness may
descend from 1-4 cm below the costal margin
- The upper border of liver dullness is located between the left
fifth and seventh intercostal spaces.
- The normal liver span at the MCL is 6-12 cm(greater in men
and taller client)
- The normal liver span at the MSL is 4–8 cm.
Abnormal Findings:
- The upper border of liver dullness may be difficult to estimate if
obscured by pleural fluid of lung consolidation.
- Hepatomegaly, a liver span that exceeds normal limits (enlarged),
is characteristic of liver tumors, cirrhosis, abscess, and vascular
engorgement.
- Atrophy of the liver is indicated by a decreased span
- A liver in a lower position than normal or a higher position than
normal
- An enlarged liver may be roughly estimated (not accurately) when
more intense sounds outline a liver span or borders outside the
normal range

10. Percuss the spleen. (side)

Percuss the spleen.
Begin posterior to the left mid-axillary line (MAL), and
percuss downward, noting the change from lung resonance to
splenic dullness.
Normal Findings: The spleen is an oval area of dullness
approximately 7 cm wide near the left tenth rib and slightly
posterior to the MAL.
Abnormal Findings: Splenomegaly is characterized by an area
of dullness greater than 7 cm wide.
-The enlargement may result from traumatic injury, portal
hypertension, and mononucleosis
11. Perform blunt percussion on the liver and the kidneys.
(sitting position)
Normal Findings: No tenderness is elicited.
 Abnormal Findings: Tenderness elicited over the liver may
be associated with inflammation or infection
Perform blunt percussion on the kidneys at the
costovertebral angles (CVA) over the twelfth rib
Normal Findings: no tenderness or pain is elicited or reported
by the client. The examiner senses only a dull thud.
Abnormal Findings: Tenderness or sharp pain elicited over
the CVA suggests kidney infection (pyelonephritis), renal
calculi, or hydronephrosis

12. Perform light palpation, noting tenderness or guarding in

all quadrants.
Normal Findings: Abdomen is nontender and soft. There is
no guarding
Abnormal Findings: Involuntary reflex guarding is serious
and reflects peritoneal irritation.

13. Perform deep palpation, noting tenderness or masses in

all quadrants.
- Note their location, size (cm), shape, consistency,
demarcation, pulsatility, tenderness, and mobility.
Normal Findings: No palpable masses are present.
Abnormal Findings: A mass detected in any quadrant may be
due to a tumor, cyst, abscess, enlarged organ, aneurysm, or
adhesions

14. Palpate the umbilicus. (Swelling, bulges, masses)

Normal Findings: Umbilicus and surrounding area are free of
swellings, bulges, or masses.
 Abnormal Findings: A soft center of the umbilicus can be a
potential for herniation. Palpation of a hard nodule in or around
the umbilicus may indicate metastatic nodes from an occult
gastrointestinal cancer
15. Palpate the aorta.
Use your thumb and first finger or use two hands and
palpate deeply in the epigastrium, slightly to the left of
midline. Assess the pulsation of the abdominal aorta.
Normal Findings: The aorta is approximately 2.5–3.0 cm
wide with a moderately strong and regular pulse. Possibly mild
tenderness may be elicited.
Abnormal Findings:
- A wide, bounding pulse
- A prominent, laterally pulsating mass above the
umbilicus with an accompanying audible bruit strongly
suggests an aortic aneurysm

16. Palpate the liver, noting consistency and tenderness.

Note consistency and tenderness.
Bimanual Palpation:
- Stand at the client’s right side and place your left hand under
the client’s back at the level of the eleventh to twelfth ribs.
- Lay your right hand parallel to the right costal margin (your
fingertips should point toward the client’s head). - Ask the
client to inhale, then compress upward and inward with your
fingers
Normal Findings: The liver is usually not palpable, although
it may be felt in some thin clients.
-If the lower edge is felt, it should be firm, smooth, and
even. Mild tenderness may be normal.
 Abnormal Findings: A hard, firm liver may indicate cancer. -
Nodularity may occur with tumors, metastatic cancer, late
cirrhosis, or syphilis.
- Tenderness may be from vascular engorgement , acute
hepatitis, or abscess.
- A liver more than 1–3 cm below the costal margin
is considered enlarged
Palpation by hooking
-Stand to the right of the client’s chest.
- Curl (hook) the fingers of both hands over the edge of the
right costal margin.
- Ask the client to take a deep breath and gently but firmly pull
inward and upward with your fingers
Abnormal Findings: Enlargement may be due to hepatitis,
liver tumors, cirrhosis, and vascular engorgement.
Normal Findings: The liver is usually not palpable, although
it may be felt in some thin clients.
-If the lower edge is felt, it should be firm, smooth, and
even. Mild tenderness may be normal.

Abnormal Findings: A hard, firm liver may indicate cancer. -

Nodularity may occur with tumors, metastatic cancer, late
cirrhosis, or syphilis.
- Tenderness may be from vascular engorgement, acute
hepatitis, or abscess.
- A liver more than 1–3 cm below the costal margin
is considered enlarged

17. Palpate the spleen noting consistency and tenderness.

- Stand at the client’s right side, reach over the
 abdomen with your left arm, and place your hand under
the posterior lower ribs.
-Pull up gently. Place your right hand below the left
costal margin with the fingers pointing toward the client’s
head.
- Ask the client to inhale and press inward and
upward as you provide support with your other hand

Normal Findings: The spleen is seldom palpable at the left

costal margin. Rarely, the tip is palpable in the presence of a
low, flat diaphragm or with deep diaphragmatic descent on
inspiration. If the edge of the spleen can be palpated, it should
be soft and nontender.
Abnormal Findings:
- A palpable spleen suggests enlargement (up to three
times the normal size)
- The splenic notch may be felt, which is an indication of
splenic enlargement.

18. Palpate the kidneys.

-To palpate the right kidney, support the right posterior
flank with your left hand and place your right hand in the
RUQ just below the costal margin at the MCL.
- To capture the kidney, ask the client to inhale. Then
compress your fingers deeply during peak inspiration. Ask
the client to exhale and hold the breath briefly. Gradually
release the pressure of your right hand. If you have
captured the kidney, you will feel it slip beneath your
fingers. To palpate the left kidney, reverse the procedure
 Normal Findings: - The kidneys are usually not palpable. If
palpated, it should feel firm, smooth, and rounded. The kidney
may or may not be slightly tender.
Abnormal Findings: - An enlarged kidney
19. Palpate the urinary bladder.
- Palpate for a distended bladder when the client’s history
or other findings warrant.
- Begin at the symphysis pubis and move upward and
outward to estimate bladder borders
Normal Findings: -An empty bladder is neither palpable nor
tender.
Abnormal Findings: - A distended bladder is palpated as a
smooth, round, and somewhat firm mass extending as far as
the umbilicus. It may be further validated by dull percussion
tones

20. Perform the test for shifting dullness.

TEST FOR ASCITES.
If client has ascites (distended abdomen or bulging flanks)
perform this special percussion technique.
- The client should remain supine.
- Percuss the flanks from the bed upward toward the
umbilicus.
- Note the change from dullness to tympany and mark this
point. Now help the client turn onto the side. Percuss the
abdomen from the bed upward. Mark the level where
dullness changes to tympany.
 21. Perform the fluid wave test.
- The client should remain supine. (need assistance )
- Ask the client or an assistant to place the ulnar side of
the hand and the lateral side of the forearm firmly along
the midline of the abdomen.
- Firmly place the palmar surface of the fingers and hand
against one side of the client’s abdomen.
- Use your other hand to tap the opposite side of the
abdominal wall
Normal Findings: No fluid wave is transmitted.
Abnormal Findings: Movement of a fluid wave against the
resting hand suggests large amounts of fluid are present
(ascites).

22. Perform the ballottement test.

Place you one hand on the patients back and one on top
and ask the patient to breath in and out move your hands
together and try to feel the kidney do it also on the other side

23. Perform tests for appendicitis:

Rebound tenderness (blumberg’s sound)
- palpate deeply at 90 degrees into the abdomen away from
the painful or tender area
 - Then suddenly release pressure
-Listen and watch for the client’s expression of pain. Ask the
client to describe which hurt more—the pressing in or the
releasing—and where on the abdomen the pain occurred.
- Normal Findings: No rebound tenderness is present.
- Abnormal Findings: The client perceives sharp, stabbing pain
as the examiner releases pressure from the abdomen
(Blumberg’s sign).
- If the client feels pain at an area other than where you were
assessing for rebound tenderness, consider that area as the
source of the pain
Test for referred rebound tenderness.
- Palpate deeply in the LLQ and quickly release pressure.
Normal Findings: No rebound pain is elicited.
Abnormal Findings: Pain in the RLQ during pressure in the
LLQ is a positive Rovsing’s sign. It suggests acute appendicitis
RLQ LLQ

Rovsing’s sign
palpate the LLQ nya tapos ang resulta e masasaktan sya sa
RLQ nya big sabihin positive for acute appendicitis sya
Referred rebound tenderness
test for peritoneal irritation (acute appendicitis)
Psoas sign (paa)
Ask the client to lie on the left side. Hyperextend the right leg of
the client.
Normal Findings: No abdominal pain is present.
Abnormal Findings: Pain in the RLQ (psoas sign) is associated
with irritation of the iliopsoas muscle due to appendicitis
Obturator sign
Support the client’s right knee and ankle.
Flex the hip and knee
Rotate the leg internally and externally
Normal Finding: No abdominal pain is present.
Abnormal finding: Pain in the RLQ indicates irritation of the
obturator muscle

Hypersensitivity test
- Stroke the abdomen with a sharp object (e.g., broken cotton
tipped applicator or tongue blade) or grasp a fold of skin with
your thumb and index finger
- Quickly let go.
- Do this several times along the abdominal wall.
Normal Finding: The client feels no pain and no exaggerated
sensation.
Abnormal Finding: Pain or an exaggerated sensation felt in the
RLQ is a positive skin hypersensitivity test and may indicate
appendicitis
24. Perform test for cholecystitis (Murphy’s sign).
Press the fingertips under the liver border at the right
costal margin and ask the client to inhale deeply.
Normal Finding: No increase in pain is present.
Abnormal Finding: Accentuated sharp pain that causes the
client to hold his or her breatm mh (inspiratory arrest)