Health Assessment

Inspection

1 2
Skin may be paler than
the general skin. No unusual
Scattered fine veins may odour is
Inspect the skin, Inspect the
be visible. New striae noted.
noting color, umbilicus, noting
are pink or bluish. Pale
vascularity, smooth, minimally color, location,
striae, scars, and raised old scars. No and contour.
lesions. lesions or rashes.

Abdomen is flat,
3 rounded, or 4 Abdomen is
symmetric. It
scaphoid.
Inspect the Inspect the does not bulge
Abdomen should
contour of the symmetry of the when client
be evenly
abdomen abdomen raises head.
rounded.

*an abnormal finding

 Inspection (cont.)
5 Respiratory movement
may be seen, especially
Inspect the abdominal in male clients. A slight
movement, noting pulsation of the
respiratory abdominal aorta,
movement, aortic peristaltic waves are
pulsations, and/or not seen.
peristaltic waves.

Auscultation

1 A series of
intermittent,
Auscultate for
bowel sounds, soft clicks and
noting intensity, gurgles are
pitch, and heard at a rate
of 5-30 per
minute.

2 Bruits are not

normally heard over
Auscultate for
vascular sounds abdominal aorta or
and friction renal, iliac or
rubs. femoral arteries.
 Percussion
Generalized tympany
Lower border of the
1 predominates over the 2 liver dullness is located
abdomen because of at the costal margin to
Percuss the air in the stomach and Percuss 1-2 cm below. The
abdomen for intestines. the liver. upper border of liver
tone. dullness is located
between the left fifth
and seventh intercostal
spaces.

Oval area of
3 dullness
approximately 7 cm
wide near the left
4
Percuss the
tenth rib and slightly Perform blunt Normally, no
spleen.
posterior to the Mid percussion on tenderness is
Axillary Line. the liver and the
elicited.
kidneys.

Palpation

1
Perform light Nontender and
palpation, noting soft, no
or tenderness guarding.
guarding in all
quadrants.
 Palpation (cont.)
Normal (mild)
Umbilicus and
2 tenderness is
possible over the 3 surrounding are
xiphoid, aorta, free of swellings,
Perform deep
cecum, sigmoid Palpate the bulges, or
palpation, noting
colon, and ovaries umbilicus. masses.
tenderness or
with deep palpation.
masses in all
quadrants.

Usually not
Approximately 5 palpable,
4 2.5-3.0 wide with although it may
a moderately Palpate the liver, be felt in some
Palpate the strong and noting thin clients.
aorta. regular pulse. consistency and
tenderness.

5 Seldom palpable at the left

costal margin. Rarely, the
tip is palpable in the
Palpate the
presence of a low, flat
spleen, noting diaphragm or with deep
consistency diaphragmatic descent on
and inspiration.
tenderness.
 Palpation (cont.)

Usually not An empty bladder

6 palpable. If 7 is neither
palpated, it should palpable nor
Palpate the be smooth, firm, Palpate the tender.
kidneys. and rounded. urinary
bladder.

The borders
8 between tympany
and dullness remain
9 No fluid wave
constant throughout is transmitted.
Perform the Perform the
position changes.
test for fluid wave
shifting test.
dullness.

NORMAL FINDING
10
Perform the
ballottement
test.
 Palpation (cont.)

11 No rebound
12 No
tenderness is
tenderness is
Perform Rovsing elicited.
elicited.
Rebound Sign.
Tenderness.

13 No rebound
pain is
Referred
elicited. 14 No abdominal
pain is
rebound present.
Psoas Sign.
tenderness.

15 No abdominal
pain is
Obturator
present.
sign.
 Palpation (cont.)

16 Client feels no
pain and no
Hypersensitivity exaggerated
test. sensation.

17 No increase in
pain is
Murphy Sign present.