1.

GATHER EQUIPMENT

- Pillow/ towel, centimeter ruler, stethoscope, marking pen, gloves, clean gown

2. EXPLAIN PROCEDURE to client.

Jhaz: Good afternoon sir I am… May I know your name? How would you like me to call you??

Jhaz: Okay sir, today I am going to assess your Abdomen. At some point I’ll be touching and palpating
you. Is that okay with you?

3. Assists client to PUT ON A GOWN.

Jhaz: Sir kindly lie down po.

Jhaz: Sir is it okay to put your clothes up to expose your abdomen since this is the part where I will
assess your abdomen?

Patient: Yes

ABDOMEN

1. INSPECT THE SKIN

I will take note of the color, vascularity, if there are any presence of striaes, scars, and if there are
lesions and rashes (WEAR GLOVES TO INSPECT LESIONS)

Note: If there are scars in the patient’s abdomen we need to measure and take note how long the
surgical scar

FINDINGS: For my patient, I did not see any

2. Inspects the umbilicus, noting color, location and contour.

3. Inspects the contour of the abdomen. Looks across the abdomen at eye level from the client's side.

4. Inspects the symmetry of the abdomen.

5. Inspects abdominal movement, aortic pulsations, and or peristaltic waves.

6. Auscultates for bowel sounds, noting intensity, pitch and frequency

7. Auscultates for vascular sounds

8. Percusses for tone.

9. Percusses the liver.

10. Performs the scratch test.

11. Percusses the spleen.

12. Performs the blunt percussion on the liver and the

kidneys.

13. Performs light palpation, noting tenderness, or masses in

all quadrants.

14. Performs deep palpation, noting tenderness or masses in

all quadrants.

15. Palpates the umbilicus & surrounding area for swelling,

bulges & masses.

16. Palpates the aorta.

17. Palpates the liver, noting consistency and tenderness.

18. Palpates the spleen, noting consistency and tenderness.

19. Palpates the kidneys.

20. Palpates the urinary bladder.

21. Performs the test for shifting dullness.

22. Performs the fluid wave test.

23. Performs the ballottement test.

24. Performs the following test for appendicitis:

a. Rebound tenderness

b. Rovsing's sign

c. Referred rebound tenderness

d. Psoas sign

e. Obturator Sign

f. Hypersensitivity test

25. Performs test for cholecystitis (Murphy's sign)

Analysis of Data

1.Formulates nursing diagnoses (wellness, risk, actual)

2. Formulates collaborative problems.

3.Makes necessary referrals