Assessing Abdomen

Purposes

1. As part of comprehensive health examination

2. To explore GI complaints
3. To assess abdominal pain, tenderness or masses
4. To monitor the client post operatively

General Considerations

1. The order of abdominal assessment is INSPECTION, AUSCULTATION, PERCUSION and

PALPATION. Auscultation is performed second because palpation and percussion may alter
bowel sounds.
2. Adjust the bed level as necessary and approach patient from the right side.
3. Use tangential lighting, if available, for optimal visualization of the abdomen.
4. Anticipate various concerns of the client so observe for verbal and non-verbal cues.
5. Warm hands are essential for abdominal examination.
6. Ask the client to empty the bladder before examination.
7. Instruct client to remove clothes and to put on a gown.
8. Help the client to lie supine with the arms folded across the chest or resting by the sides. Raising
arms above the head or folding behind the head will tense the abdominal muscles.
9. Drape patient from xiphoid process to the symphysis pubis, then expose the patient’s abdomen
10. Stand to the right side of the patient for examination

Examination Normal Findings Abnormal Findings Pathophysiology

INSPECTION
Contour
View the contour of the
patient’s abdomen from the
coubstal margin to the
symphysis pubis.
The abdominal Large convex A large convex abdomen
contour is flat (straight symmetrical profile can result from the 7 Fs.
horizontal line from from the costal margin 1. Fat
costal margin to to the symphysis 2. Fluid (Ascites)
symphysis pubis) or pubis. 3. Flatus
rounded (convexity of 4. Feces
abdomen from costal 5. Fetus
margin to symphysis 6. Fatal growth
pubis) (malignancy)
7. Fibroid tumor

A scaphoid abdomen
reflects a decrease in fat
A concave deposits, a malnourished
symmetrical profile state, or flaccid muscle
from the costal margin tone.
to the symphysis pubis
is abnormal
Symmetry
1. View the symmetry The abdomen should Assessment reveals an Asymmetry may be caused
of the patient’s be symmetrical asymmetrical by a tumor, cysts, bowel
abdomen from the bilaterally abdomen/ obstruction, enlargement
costal margin to the of abdominal organs, or
symphysis pubis scoliosis, bulging at the
2. Move to the foot of umbilicus can indicate an
the examination umbilical hernia.
 table and recheck
the symmetry of If the is asymmetrical at
the patient’s the site of a surgical
abdomen incision or scar, suspect an
incisional hernia
Rectus abdominis muscles
1. Instruct the patient The symmetry of the A ridge is observed This abnormality is known
to raise the head abdomen remain between the rectus as diastasis recti
and shoulders off uniform; no ridge is abdominis muscles abdominis and is
the examination observed parallel to attributed to marked
table the umbilicus or obesity or past pregnancy.
2. Observe the rectus between the rectus The observed separation is
abdominis muscles abdominis muscles due to increased intra-
for separation abdominal pressure and is
not considered to be
harmful or ominous
Pigmentation and Color
1. View the color of The abdomen Uneven skin Presence of jaundice
the patient’s suggest liver dysfunction,
abdomen from the should be color or due to accumulation of
costal margin to the uniform in pigmentation bilirubin in the blood
symphysis pubis
color and is abnormal In light skinned individuals
pigmentation the observation of blue
tint at the umbilicus
suggests free blood in the
cavity known as Cullen’s
sign.
Such bleeding can occur
either following rupture of
fallopian tube secondary
to an ectopic pregnancy or
with acute hemorrhagic
pancreatitis.
Irregular patches of tan
skin pigmentation (café au
lait spots) may be
attributed to
Recklinghausen’s disease,
a familial condition
associated with formation
of neurofibromas.

The appearance of
engorged or dilated veins
around the umbilicus is
called caput medusa. It is
associated with circulatory
obstruction of the
Superior vena cava (SVC)
or IVC Inferior vena Cava.
In some condition it is
related to obstruction of
the portal vein or to
emaciation
Scars
2. Inspect the There should be no Scars are present The site of the scars
abdomen for scars abdominal scar discloses useful
 from costal margin present information about the
to the symphysis patient’s surgical history.
pubis Dense, irregular,
collagenous scars are
keloids, which are more
common in dark-skinned
individuals and may be
associated with traumatic
injuries and burns
Striae
 Observe the Striae is present Striae, strophic lines or
No evidence of streaks occur when there
abdominal skin for
striae, or abdominal striae is present has been rapid or
atrophic lines or prolonged stretching of
scars the skin. Abdominal striae
may be caused by Cushing
syndrome, abdominal
tumors, obesity, ascites, or
pregnancy. Following
pregnancy, striae are
normal finding.
Respiratory movement
 Observe the There is no evidence Abnormal respiratory The origin of abnormal
abdomen for of respiratory movements and respiration due to an
smooth, even retractions. Normally, retractions are abdominal disorder may
respiratory the abdomen rises observed include appendicitis with
movement with inspiration and local peritonitis,
falls with expiration pancreatitis, biliary colic,
or a perforated ulcer
Masses or nodules
 Observe abdominal No masses or Masses or The presence of
skin for nodules or abdominal masses or
nodules are nodules are nodules may indicate
masses
present present tumors, metastases of an
internal malignancy , or
pregnancy
Pulsation
 Inspect the In patient with a Marked strong Widened pulse pressure
epigastric area for normal build, a and strong epigastric
nonexaggerated
pulsations are pulsations may indicate an
pulsations
pulsation of the observed aortic aneurysm. An
abdominal aorta may exaggerated pulsation can
be visible in the also occur in aortic
epigastric area. In regurgitation and in the
heavier patients, right ventricular
pulsations may not be hypertrophy
visible.
Umbilicus
1. Observe the The umbilicus is The umbilicus Umbilical hernia in the
umbilicus in adult is the protrusion of
relation to
depressed and protrudes part of the intestine
abdominal beneath the above the through an incomplete
surface abdominal umbilical ring.
2. Ask the patient surface
abdominal
to flex the neck surface It is confirmed by inserting
and perform a finger in the navel and
the valsalva feeling an opening in the
maneuver fascia
 3. Observe for
protrusion of The umbilicus that
the intestine appears as a nodule may
xthrough the be a manifestation of
umbilicus abdominal carcinoma with
metastasis on the
umbilicus. The physical
finding is known as Sister
Mary Joseph nodule

Intra-abdominal pressure
from ascites, masses or
pregnancy can cause the
umbilicus to protrude
Auscultation
Bowel Sounds
1. Place the Bowel sounds are Indicative of late intestinal
diaphragm lightly heard as intermittent Absent bowel obstruction, both
on the abdominal gurgling sounds sounds mechanical and non-
wall beginning at throughout the mechanical in nature.
the RLQ. abdominal quadrants. Mechanical
2. Listen to the Usually, they are high
frequency and pitched sounds and
obstruction of the
bowel may result from
character of the occur 5 to 30 times
extra luminal lesions such
bowel sounds. It is per minute. Bowel
as adhesions, hernias, and
necessary to listen sounds result from the
masses.
for 5 minutes in an movement of air and
abdominal fluid through the Non mechanical
quadrant before gastrointestinal tract. obstruction, the
concluding that Normally, bowel gastrointestinal lumen
bowel sounds are sounds are always remains unobstructed but
absent present at the the muscles of the
3. Move diaphragm to ileocecal valve at the intestinal wall cannot
RUQ,LUQ, LLQ RLQ. move its content. This
obstruction can be caused
Normal hyperactive by physiological,
bowel sounds are neurogenic or chemical
called borborygmi. imbalances that result on
They are loud, audible, Paralytic ileus.
gurgling sounds. It is
due to the hyper
peristalsis (“stomach
growling”) or the
sound of flatus in the
intestines

Hypoactive or diminished
Hypoactive bowel sounds indicate
bowel sounds are decreased motility of the
abnormal bowel and can occur with
peritonitis and non-
mechanical obstruction.
Other causes include
inflammation, gangrene ,
electrolyte imbalances
and intraoperative
 manipulation of the
bowel.

Hyperactive or increased
Hyperactive bowel sounds signify
increased motility of the
bowel sounds are bowel and can result from
abnormal gastroenteritis, diarrhea,
laxative use and subsiding
ileus.

Auscultation of high-
pitched tinkling
hyperactive bowel sounds
id indicative of partial
obstruction. These sounds
are caused by the
powerful peristaltic
actions of the bowel
segment attempting to
eject its contents through
a narrow, constricted
area. Frequently patients
complain of abdominal
cramping

Vascular sounds
 Place the bell of the No audible Audible bruits A bruit over an abdominal
stethoscope over vessel indicates
the abdominal bruits are are turbulence of blood flow
aorta, renal auscultated auscultated and suggests a partial
arteries, iliac obstruction. Bruits can
arteries, and occur with abdominal
femoral arteries aortic aneurysm, renal
 Listen for bruits stenosis, and femoral
over each area stenosis.

If you hear bruits do not

palpate or percuss in that
area. It may cause
rupture.
Percussion
General Percussion
1. Percuss all 4 Tympany is the Dullness over Dullness may be
quadrants in a predominant sound
systematic manner. heard because air is
areas where caused by a mass or
Begin percussion in present in the tympany tumor, pregnancy,
RLQ moving upward stomach and in the normally occurs, ascites, or a full
to the RUQ crossing intestines. such as over the intestine
over LUQ, and
moving down to the In obese patients it
stomach and
LLQ may be difficult to intestines, is
2. Visualize each organ elicit tympany due to considered
in corresponding the quantity of abnormal
quadrant; note adipose tissue.
when tympany Dullness is normally
changes to dullness heard over organs
 such as the liver or a
distended bladder.
Dull sounds are high-
pitched and of
moderate duration.
Fist Percussion
Is done over the kidneys
and liver to check for
tenderness.

Kidney
 Place the patient in No tenderness CVA tenderness can
Tenderness or
a sitting position
should be elicited pain over the occur in
 Strike the
costovertebral costovertebral pyelonephritis
angle with a closed angle is
fist (direct fist
percussion) or place
abnormal
the palmar surface
of one hand over
the costovertebral
angle. Strike that
hand with the ulnar
surface of the fist of
the other hand
(indirect fist
percussion)
 Ask the patient
what was felt.
Observe the
patient’s reaction
 Repeat on the other
side.
Liver
 Place the patient in
a supine position No tenderness
 Place the palmar should be elicited Liver tenderness can
surface of one hand Tenderness or occur in conjunction
over the lower right pain over the with cholecystitis or
rib cage liver is abnormal
 Strike that hand hepatitis
with the ulnar
surface of the fist of
the other hand
 Ask the patient
what was felt.
Observe the
patient’s reaction
Palpation
Before palpation
assessment asks the patient
to cough. Coughing can
elicit a sharp twinge of pain
in the involved area if
peritoneal irritation is
present. Palpate the
involved area last.
Light palpation
 With your arms and The abdomen should Light palpation reveals Tenderness and elevated
forearm on a feel smooth with changes in skin skin temperature can be
horizontal plane,use consistent softness temperature, due to inflammation.
the pads of the tenderness, or large Large masses can be due
approximated masses to tumors, feces, or
fingers to depress enlarged organs
the abdominal wall
1 cm.
 Avoid short, quick
jabs
 Lightly palpate all
four quadrants in a
systematic manner
Abdominal Muscle
Guarding Muscle guarding or Muscle guarding Involuntary muscle
To determine whether tensing of the
abdominal
of the rectus guarding suggests
muscle guarding is
involuntary musculature, is absent muscle occurs irritation of the
 Perform light during expiration. The during expiration peritoneum, as in
palpation of the abdomen is soft. peritonitis.
rectus muscles Normally during
during expiration expiration the patient
 Note muscle cannot exercise
tensing voluntary muscle
tensing

Advanced Techniques

Examination Normal Findings Abnormal Pathophysiology

findings
Assessing For Ascites
(fluid Wave)
 With the patient on
No fluid wave A fluid wave is Increased vascular
a supine position,
stand at the should be felt easily felt if a resistance to hepatic
patient’s right side large amount of outflow.
 Have the patient or ascites is
second nurse firmly
place the ulnar side
present. This sign Portal hypertension.
of the right hand is often negative
midline on the until the ascites Hypoalbuminemia
abdomen to prevent is obvious. In and decreased
placement of fat
 Place your right
addition, the colloid osmotic
hand on the fluid wave is pressure
patient’s right hip or sometimes
 flank area. Reach positive in Disordered kidney
across the patient
with your left hand
people without function
a deliver a blow to ascites
the patient’s left hip Excessive secretion
or flank area of antidiuretic
 Assess if a fluid
wave is felt on the
hormone
right hand of the
patient or the other
nurse.
Assessing for
Cholecystitis:
Murphy’s Sign
 With the patient No pain is Pain is present Murphy’s sign is
supine, stand at the elicited with palpation. positive in
patient’s right side
The patient may inflammatory
 Palpate below the
stop inhaling to processes of the
liver margin at the
lateral of the rectus guard against the gallbladder such as
muscle pain. This is cholecystitis
 Have the patient known as
take a breath Murphy’s sign
Assessing for
Appendicitis: Pressing the LLQ
Rovsing’s sign traps air within the
Is a differential technique No pain should Abdominal pain large intestine and
to elicit referred pain, be elicited felt on the RLQ is increases the
reflective of peritoneal
inflammation secondary to
abnormal and is pressure in the
appendicitis a positive cecum. When the
 Press deeply and Rovsing’s sign appendix is
evenly in the LLQ for inflamed, this
5 seconds
 Note the patient’s
increase in pressure
response causes pain.
Assessing for
Appendicitis:
Iliopsoas Muscle test
When patient presents with Normally, the The patient The pain indicates
acute abdominal pain, an
inflamed or perforated
patient should experience pain inflammation of the
appendix may be experience no in the RLQ iliopsoas muscle in
distinguished via irritation of pain the groin and is
the lateral iliopsoas muscle caused by an
 Place a hand over
inflamed appendix
the right thigh
and push downward
as the patient raises
the leg, flexing at
the hip
 Observe for pain
response in the RLQ
as described by the
 patient

Assessing for Appendicitis or

:Obturator
Pelvic Abscess
Muscle Test The pain indicates
 Flex the right leg at
the hip and knee at
No pain is Pain is elicited in irritation of the
a right angle elicited with this the hypo gastric obturator muscle
 Rotate the leg both maneuver area and can be caused
internally and by a ruptured
externally
 Observe for pain
appendix or pelvic
response abscess