Republic of the Philippines

President Ramon Magsaysay State University

(formerly Ramon Magsaysay Technological University)
Iba, Zambales, Philippines
Tel/Fax No.: (047) 811-1683

COLLEGE OF NURSING
Name:________________________________Section/Group:_______________Date:___________
Rating

5 Correctly and independently performs procedure and states complete rationale

4 Performs procedure and states rationale with minimal guidance
3 Satisfactorily performs procedure with moderate guidance
2 Procedure incorrectly done without rationale
1 Procedure not performed
Assessing the Abdomen
PROCEDURE 5 4 3 2 1
Assemble the equipment:
 Examining light
 Tape measure (metal or unstretchable cloth)
 Water-soluble-skin-marking pencil
 Stethoscope
1. Introduce yourself and verify the client’s identity.
Explain to the client what you are going to do, why it is
necessary, and how she can cooperate.
2. Perform hand hygiene and observe other appropriate
infection control procedure
3. Provide client privacy
4. Determine the client’s history of the following:
 Incidence of abdominal pain: its location, onset,
sequence, and chronology; its quality
(description); its frequency; associated
symptoms
 Bowel habits
 Incidence of constipation or diarrhea
 Change in appetite
 Food intolerance
 Food ingested in last 24 hrs
 Specific signs and symptoms
 Previous problems and treatment
5. Assist the client to a supine position, with the arm
placed comfortably at the sides.
 Place small pillows beneath the knees and the
head to reduce tension in the abdominal
muscles. Expose only the client’s abdomen from
chest line to the pubic area to avoid chilling and
shivering, which can tense the abdominal
muscles.
Assessment: Inspection in the Abdomen
6. Inspect the abdomen for skin integrity.
 Observe the abdominal contour while standing
at the client’s side when the client is supine
 Ask the client to take a deep breath and to hold
it.
 Assess the symmetry of contour while standing
 Republic of the Philippines
President Ramon Magsaysay State University
(formerly Ramon Magsaysay Technological University)
Iba, Zambales, Philippines
Tel/Fax No.: (047) 811-1683

COLLEGE OF NURSING
at the foot of the bed.
 If distension is present, measure the abdominal
girth by placing a tape around the abdomen at
the level of the umbilicus.
7. Observe abdominal movements associated with
respiration, peristalsis, or aortic pulsations.
8. Observe the vascular pattern.
Auscultation of the Abdomen
9. Auscultate the abdomen for bowel sounds, vascular
sounds, and peritoneal friction rub.
Percussion of the Abdomen
10. Percuss several in each of the four quadrants to
determine presence of tympany and dullness.
 Use a systematic pattern: begin in the lower left
quadrant, then proceed to the lower right
quadrant, the upper right quadrant, and the
upper left quadrant.
Percussion of the Liver
11. Percuss the Liver to determine its size.
Palpation of the Abdomen
12. Perform light palpation first to detect areas of
tenderness and/or muscle guarding.
 Systematically explore all four quadrants
13. Perform deep palpation over all four quadrants.
Palpation of the Liver
14. Palpation of the liver
Palpation of the Bladder
15. Palpate the area above the pubic symphysis if the
client’s history indicates possible urinary retention.
16. Document findings in the client record.

Actual Score Actual Score

Computation: ×60+ 40= ×60+ 40=Grade
Total Score ❑

Grade:_______________
Remarks:__________________________________________________________________
___________________________________________________________________________
___________________________________________________________________
 Republic of the Philippines
President Ramon Magsaysay State University
(formerly Ramon Magsaysay Technological University)
Iba, Zambales, Philippines
Tel/Fax No.: (047) 811-1683

COLLEGE OF NURSING

Evaluated by:

___________________
Clinical Instructor

Conforme:

___________________
Signature of Student