Good day, I am Jordan Singa I will be performing the skills

assessing abdomen to see if the client has any alterations to

prevent any further complications
Equipment
• Tape measure (metal or unstretchable material)
• Skin-marking pen • Stethoscope
1. Prior to performing the assessment, introduce self and verify
the client’s identity using agency protocol. Explain to the client
what you are going to do, why it is necessary, and how to
participate. Discuss how the results will be used in planning
further care or treatments.
“Good afternoon, sir I am Jordan Singa from Basilan state
college a 1st year nursing student, may I know your name po?
Thank you, so sir I will be assessing your abdomen to see if
there’s any alterations to prevent any further complications ….
So sir is that ok po? .”
2. Perform hand hygiene and observe other appropriate
infection prevention procedures.
3. Provide for client privacy.
4. Inquire if the client has any history of the following:
-Do you feel any pain in your abdomen.
- any constipation or diarrhea
- have you noticed any changes in your appetite
- any problems urinating such as pain or burning sensation
5. Assist the client to a supine position, with the arms placed
comfortably at the sides. Place small pillows beneath the knees
and the head to reduce tension in the abdominal muscles.
Expose the client’s abdomen only from the chest line to the
pubic area to avoid chilling and shivering, which can tense the
abdominal muscles.
6. Inspect the abdomen for skin color, contour, pulsations, the
umbilicus, and other surface characteristics (rashes, lesions,
masses, scars). If distention is present, measure the abdominal
girth by placing a tape around the abdomen at the level of the
umbilicus. ❶ If girth will be measured repeatedly, use a skin-
marking pen to outline the upper and lower margins of the tape
placement for consistency of future measurements.
“Sir, let me inspect your abdomen”
“Upon inspection, the abdomen is flat and symmetrical, no
presence of scars, lashes, rashes, no donated veins distensions
or enlarged organs. Umbilicus is midline without herniation
which is a normal finding.”
7. Auscultate all four quadrants of the abdomen for bowel
sounds by using the diaphragm of the stethoscope and make
sure that it is warm before you place it on the client’s
abdomen. Apply light pressure or simply rest the stethoscope
on a tender abdomen. Begin in the RLQ and proceed clockwise,
covering all quadrants. Confirm bowel sounds in each quadrant.
Listen for up to 5 minutes (minimum of 1 minute per quadrant)
to confirm the absence of bowel sounds. Note the intensity,
pitch, and frequency of the sounds.
“Now sir, allow me to auscultate your abdomen for bowel
sounds. I’ll start on your Right Lower quadrant, Right Upper
quadrant, left upper quadrant, left lower quadrant.”
“Upon auscultation a series of intermittent, soft clicks and
gurgles are heard at a rate of 20 bowel sound per minute which
is a normal findings.”
Rationale: Normal bowel sounds are 5-30 per minute, if the
bowel sound is higher than 30 then it is called “Hyperactive”
bowel sounds that are rushing, tinkling, and high pitched may
be abnormal indicating very rapid motility heard in early bowel
obstruction, gastroenteritis, diarrhea, or with use of laxatives.
While below 5 it is called “Hypoactive” bowel sounds indicate
diminished bowel motility. Common causes include paralytic
ileus following abdominal surgery, inflammation of the
peritoneum, or late bowel obstruction.
8. Auscultate for vascular sounds. Use the bell of the
stethoscope to listen for bruits (low-pitched, murmur-like
sound, pronounced BROO-ee) over the abdominal aorta and
renal, iliac, and femoral arteries.
“Next po I’ll auscultate naman for any vascular sounds.”
“Upon auscultating for vascular sounds, I don’t hear no sounds
which is normal.”
Rationale: If bruits are noted and heard this suggest that there
is a disturbances in the blood flow that is caused by arterial
stenosis
9. Percuss several areas in each of the four quadrants to
determine presence of tympany (sound indicating gas in
stomach and intestines) and dullness (decrease, absence, or
flatness of resonance over solid masses or fluid). Use a
systematic pattern.
“Sir, I’ll be tapping your abdomen is ok po ba? Now I’ll percuss
for the abdominal tone.”
“As I observed, there are presence of tympany sounds in all
four quadrants that means said it indicates that the air in the
intestine rising and that is a normal finding.”
Rationale: If dull sounds are present, this indicate that the
patient has distended bladder fluid or mass.
10. Palpate the abdomen lightly in all four quadrants and then
palpate using deep palpation technique. Light palpation is used
to identify areas of tenderness and muscular resistance. Using
the fingertips, begin palpation in a nontender quadrant, and
compress to a depth of 1 cm in a dipping motion. Then gently
lift the fingers and move to the next area. To minimize the
client’s voluntary guarding (a tensing or rigidity of the
abdominal muscles usually involving the entire abdomen). Keep
in mind that the rectus abdominis muscle relaxes on expiration.
It is important to ask the client first prior to perform the
assessment if he or she has any pain that is currently present to
avoid palpating the area first.
“Sir do you have any pain currently on your abdomen? Now
naman po I’ll lightly palpate your abdomen, I’ll start on the
right lower quadrant, RUQ, LUQ,LLQ”
“I observed that the Abdomen is nontender and soft. There is
no guarding”
12. Deeply palpate all quadrants to delineate abdominal organs
and detect subtle masses. Using the two palmar surfaces of
both hands, compress to a maximum depth (5–6 cm). Perform
bimanual palpation if you encounter resistance or to assess
deeper structures
“Now, I’m going to deeply palpate your abdomen po, ok lang
po ba?”
“I observed that there are no signs of tenderness or pain and no
guarding movement as well and all are normal findings.”
13. Assess for rebound tenderness. If the client has abdominal
pain or tenderness, test for rebound tenderness by palpating
deeply at 90 degrees into the abdomen away from the painful
or tender area then suddenly release. Listen and watch for the
client’s expression of pain. Ask the client to describe which hurt
more the pressing in or the releasing and where on the
abdomen the pain occurred.
“Ngayon naman po I’ll assess for rebound tenderness, I’m going
to deeply palpate your abdomen.”
“ No rebound tenderness is present.”
Rationale: If facial grimacing and guardging movement is
present then the patient is positive for rebound tenderness,
peritonitis is the sign which is an inflammation of the
peritoneum or aneurysm.
14. Palpate the femoral arteries. Ask the client to bend the
knee and move it out to the side. Press deeply and slowly
below and medial to the inguinal ligament. Use two hands if
necessary. Release pressure until you feel the pulse. Repeat
palpation on the opposite leg. Compare amplitude bilaterally
“sir I need to have access on your inner thigh area so is that ok
with you? I’ll start on the left then next on the right”
“I observed that the bilateral femoral process are equal in
terms of rate and rhythm, the strength as well. “
Rationale: assessing the pulse of the patient in the femoral
pulses, need to have assess it based on the grading scale from
0-4. If pulse is not present then it is considered as 0, if barely
felt palpable then it s 1, then so on and so fort.
15. Auscultate the femoral pulses. If arterial occlusion is
suspected in the femoral pulse, position the stethoscope over
the femoral artery and listen for bruits. Repeat for other side.
“Last part of our assessment I’ll auscultate your femoral pulse
I’ll start on the left then on the right.
“Pulses are equal in normal, symmetrical and no presence of
unequal femoral pulses.”
16. Now I finished assessing the abdomen of the patient as well
as the femoral arteries , assist the client to replace patient
gown and assist in a comfortable position.
17. Document findings in the client record using printed or
electronic forms or checklists supplemented by narrative notes
when appropriate