ABDOMINAL ASSESSMENT

The abdomen is bordered superiorly by the costal margins, inferiorly by the symphysis pubis and inguinal canals, and
laterally by the flanks (Fig. 22-1)

The abdomen can be described as having four quadrants termed the right upper quadrant (RUQ), right lower
quadrant (RLQ), left lower quadrant (LLQ), and left upper quadrant (LUQ). The quadrants are determined by an
imaginary vertical line (midline) extending from the tip of the sternum (xiphoid) through the umbilicus to the symphysis
pubis. This line is bisected perpendicularly by the lateral line, which runs through the umbilicus across the abdomen.
The older method of describing abdominal locations uses (9) nine regions, pictured below.

The abdominal contents are enclosed externally by the abdominal wall musculature. which includes three layers of
muscle extending from the back, around the flanks, to the front. The outermost layer is the external abdominal
oblique; the middle layer is the internal abdominal oblique: and the innermost layer is the transverse abdominis (Fig.
22-2). Connective tissue from these muscles extends forward to encase a vertical muscle of the anterior abdominal
wall called the rectus abdominis. The fibers and connective tissue extensions of these muscles (aponeuroses)
diverge in a characteristic plywood-like patterning(several thin layers arranged at right angles to each other), which
provides strength to the abdominal wall. The abdominal wall muscles protect the internal organs and allow normal
compression during functional activities such as coughing, sneezing, urination, defecation, and childbirth.
A thin, shiny, serous membrane called the peritoneum lines the abdominal cavity (parietal peritoneum) and also
provides a protective covering for most of the internal abdominal organs (visceral peritoneum). several different body
systems: gastrointestinal, reproductive (female), lymphatic, and urinary. These structures are typically referred to as
the abdominal viscera and can be divided into two types: solid viscera and hollow viscera (Fig. 22-3). Solid viscera
are those organs that maintain their shape consistently: liver, pancreas, spleen, adrenal glands, kidneys, ovaries, and
uterus. The hollow viscera consist of structures that change shape depending on their contents.
These include the stomach, gallbladder, small intestine, colon, and bladder.

-The liver is the largest solid organ in the body. It is located below the diaphragm in the RUQ of the abdomen.
-The pancreas, located mostly behind the stomach deep in the upper abdomen. is normally not palpable.
-The spleen is approximately 7 cm wide and is located above the left kidney just below the diaphragm at the level of
the ninth, tenth, and eleventh ribs. This soft. flat structure is normally not palpable.
-The abdominal cavity begins with the stomach. It is a distensi-ble, flask-like organ located in the LUQ just below the
diaphragm and between the liver and spleen. The stomach is not usually palpable.
-The gallbladder, a muscular sac approximately 10 cm long, located near the posterior surface of the liver lateral to
the midclavicular line. It is not normally palpated.
-The small intestine, which lies coiled in all four quadrants of the abdomen, is not normally palpated.
-The colon is composed of three major sections: ascending, transverse, and descending. The ascending colon
extends up along the right side of the abdomen. At the junction of the liver in the RUQ, it flexes at a right angle and
becomes the transverse colon. 'The transverse colon runs across the upper abdomen. in the Loo near the spleen, the
colon forms another right angle then extends downward along the left side of the abdomen as the descending colon.
At this point, it curves in toward the midline to form the sigmoid colon in the LLQ. The sigmoid colon is often felt as a
firm structure on palpation, whereas the cecum and ascending colon may feel softer. The transverse and descending
colon may also be felt on palpation.

Note: Whether or not abdominal viscera are palpable depends on location, structural consistency, and size.
Note: When the spleen enlarges, the lower tip extends down and toward the midline.
-The kidneys are located high and deep under the diaphragm.

The abdominal organs are supplied with arterial blood by the abdominal aorta and its major branches (Fig. 22-5).
Pulsations of the aorta are frequently visible and palpable midline in the upper abdomen. The aorta branches into the
right and left iliac.

ABNORMALITIES/ SIGNS MAY INDICATE DISEASES

-Indigestion (pyrosis), often described as heartburn, may be an indication or acute or enronic gastric disorders
including hyperacidity, gastroesophageal reflux discase (GERD), peptic ulcer disease. and stomach cancer.

-Nausea may reflect gastric dysfunction and is also associated with many digestive disorders and diseases of the
accessory organs, such as the liver and pancreas, as well as with renal failure and drug intolerance.

-Vomiting is associated with impaired gastric motility or reflex mechanisms. Description of vomitus (emesis, is a clue
to the source.

Note: Elderly or neuromuscular or consciousness impared clients are at risk for lung aspiration with vomiting.

-Loss of appetite (anorexia) is a general complaint often associated with digestive disorders. chronic svndromes.
cancers. and psychological disorders.

Note: Older clients may experience a decline in appetite from various factors such as altered metaholism
decreased taste sensation, decreased mobility, and possibly depression. If appetite declines, the client's risk for
nutritional imbalance.

-Constipation is usually defined as a decrease in the frequency or bowel movements or the passage of hard and
possibly painful stools. Signs and symptoms that accompany constipa-ton mav be a clue as to me cause or
consudason sucn as bleeding with malignancies or pencil-shaped stools with infestinal obstruction.

-Diarrhea is defined as frequency of bowel movements producing unformed or liquid stools. Bloody and mucoid stools
are associated with inflammatory bowel diseases (e.g., ulcerative colitis, Crohn's disease); clay-
colored. fatty stools may be from malabsorption syndromes Associated symptoms or signs may suggest the
disorder's origin.

ABNORMAL FINDINGS IN ASSESSMENT

INSPECTION:
-Purple discoloration at the flanks (Grey Turner sign) indicates bleeding within the abdominal wall, possibly from
trauma to the kidneys, pancreas, or duodenum or from pancreatitis.
-The yellow hue of jaundice may be more apparent on the abdomen.
-Pale, taut skin may be seen with ascites (significant abdominal swelling indicating fluid accumulation in the
abdominal cavity).
-Redness may indicate inflammation.
-Bruises or areas of local discoloration are also abnormal
-Dilated veins may be seen with cirrhosis of the liver, obstruction of the inferior vena cava portal hypertension or
ascites.
-Dilated surface arterioles and capillaries with a central star (spider angioma) may be seen with liver disease or portal
hypertension.
-dark bluish-pink striae are associated with Cushing's syndrome.
-Striae may also be caused by ascites, which stretches the skin. Ascites usually results from liver failure or liver
disease.
-Changes in moles including size, color, and border symmetry. Any bleeding moles or petechiae (reddish or purple
lesions, mav also be abnormal
-Bluish or purple discoloration around the umbilicus (Cullen's sign) indicates intra-abdominal bleeding.
-A deviated umbilicus may be caused by pressure from a mass, enlarged organs. hernia, fluid, or scar tissue.
-An enlarged, everted umbilicus suggests umbilical hernia.
-Distention below the umbilicus may be due to a full bladder, uterine enlargement, or an ovarian tumor
or cyst. Distention of the upper abdomen may be seen with masses of the pancreas or gastrie dilation.
-A scaphoid (sunken) abdomen may be seen with severe weight loss or cachexia related to starvation or terminal
illness.

Note: major causes of abdominal distention are sometimes referred to as the "6 Fs": Fat, feces, fetus, fibroids,
flatulence, and fluid.

AUSCULTATION
-Hypoactive bowel sounds indicate diminished bowel motility.
-Hyperactive bowel sounds indicate increased bowel mouthity. Common causes include diarrhea, gastroenteritis,
or early bowel obstruction.
-A bruit with both systolic and diastolic components oceurs when blood flow in an arterv is turbulent or obstructed.
This usually indicates aneurysm or arterial stenosis.

PERCUSSION
-Accentuated tympany or hyperreso-nance 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
-The upper border of liver dullness may be difficult to estimate if obscured by percuss downward, noting the change
intercostal spaces pleural fluid of lung consolidation.
-Hepatomegaly, a liver span that exceeds normal limits (enlarged), is characteristic of liver tumors, cirrhosis, abscess
and vascular engorgement.
-Tenderness elicited over the liver may be associated with inflammation or infection (e.g., hepatitis or cholecystitis).

PALPATION
-Involuntary reflex guarding is serious and reflects peritoneal irritation.
-A mass detected in any quadrants may be due to a tumor, cyst, abscess, enlarged organ, aneurysm, or adhesions.
-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.
-A hard, firm liver may indicate cancer. Nodularity may occur with tumors, metastatic cancer, late cirrhosis, syphilis.
Tenderness may be from vascular engorgement (e.g., congestive heart failure), acute hepatitis, or abscess.
-A liver more than 1 to 3 em helow the costal margin is considered enlarged (unless pressed down by the
diaphragm).
-Enlargement may be due to hepatitis, liver tumors. cirrhosis. and vascular engorgement.

Note: Do not palpate a pulsating midline mass: it mav he a dissecting aneurysm that can rupture from the pressure
of palpation. Also avoid deep palpation over tender organs as in tne case or polycystic kidneys, wilms’ tumor,
transplantation, or suspected splenic trauma.