Abdominal

Assessment
Sherwyn U. Hatab RN.

Sherwyn Hatab RN.

The Gastrointestinal
System
• The GI system includes the GI
tract (alimentary canal),
consisting of the mouth,
esophagus, stomach, small and
large intestines, and rectum. The
salivary glands, liver, gallbladder,
and pancreas secrete substances
into this tract to form the GI
system.

Sherwyn Hatab RN.

The Gastrointestinal
System
• The main function of the GI tract, with the aid of organs such
as the pancreas and the liver, is the digestion of food to meet
the body’s nutritional needs and the elimination of waste
resulting from digestion.
• Adequate nutrition is required for proper functioning of the
body’s organs and other cells.
• The GI tract is susceptible to many health problems, including
structural or mechanical alterations, impaired motility,
infection, and cancer.
Sherwyn Hatab RN.
ABDOMINAL
QUADRANTS
• For the purposes of examination, 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.
Familiarization with the organs and structures in each
quadrant is essential to accurate data collection,
interpretation, and documentation of findings.

Sherwyn Hatab RN.

ABDOMINL
REGIONS
• Another, older method divides
the abdomen into nine regions.
Three of these regions are still
commonly used to describe
abdominal findings: epigastric,
umbilical, and hypogastric or
suprapubic.

Sherwyn Hatab RN.

 Commonly used to
describe the location
of abdominal aorta

Commonly used to
describe the
location of the
urinary bladder
Sherwyn Hatab RN.
Esophagus
• The esophagus is a muscular
canal that extends from the
pharynx (throat) to the
stomach and passes through
the center of the diaphragm.
Its primary function is to
move food and fluids from
the pharynx to the stomach.

Sherwyn Hatab RN.

Esophagus
• At the upper end of the esophagus is a
sphincter referred to as the upper
esophageal sphincter (UES). When at rest,
the UES is closed to prevent air into the
esophagus during respiration
• The portion of the esophagus just above
the gastroesophageal (GE) junction is
referred to as the lower esophageal
sphincter (LES). When at rest, the LES is
normally closed to prevent reflux of gastric
contents into the esophagus. If the LES
does not work properly, gastroesophageal
reflux disease (GERD)

Sherwyn Hatab RN.

 Stomach

• The stomach is located in the midline and left upper

quadrant (LUQ) of the abdomen and has four anatomic
regions.
• The cardia is the narrow portion of the stomach that is
below t gastroesophageal (GE) junction.
• The fundus is the area nearest to the cardia.
• The main area of the stomach is referred to as the body
or corpus.
• The antrum (pylorus) is the distal (lower) portion of the
stomach and is separated from the duodenum by the
pyloric sphincter.
• Both ends of the stomach are guarded by sphincters
(cardiac and pyloric), which aid in the transport of food
through the GI tract and prevent backflow.
Sherwyn Hatab RN.
 Stomach

• Smooth muscle cells that line the stomach

are responsible for gastric motility.
• Parietal cells lining the wall of the stomach
secrete hydrochloric acid, whereas chief
cells secrete pepsinogen (a precursor to
pepsin, a digestive enzyme).
• Parietal cells also produce intrinsic factor, a
substance that aids in the absorption of
vitamin B12. Absence of the intrinsic factor
causes pernicious anemia.

Sherwyn Hatab RN.

 Pancreas

• The pancreas is a fish-

shaped gland that lies
behind the stomach and
extends horizontally from
the duodenal C-loop to the
spleen. The pancreas is
divided into portions
known as the head, the
body, and the tail.

Sherwyn Hatab RN.

 Pancreas
• Two major cellular bodies (exocrine and
endocrine) within the pancreas have separate
functions.
• The exocrine part is about 80% of the organ and
consists of cells that secrete enzymes needed
for digestion of carbohydrates, fats, and
proteins (trypsin, chymotrypsin, amylase, and
lipase).
• The endocrine part of the pancreas is made up
of the islets of Langerhans, with alpha cells
producing glucagon and beta cells producing
insulin. These hormones produced are essential
in the regulation of metabolism.
Sherwyn Hatab RN.
Liver
• The liver is the largest organ in
the body (other than skin) and is
located mainly in the right upper
quadrant (RUQ) of the abdomen.
• The right and left hepatic ducts
transport bile from the liver.
• It receives its blood supply from
the hepatic artery and portal
vein, resulting in about 1500 mL
of blood flow through the liver
every minute.

Sherwyn Hatab RN.

 Liver
• The liver performs more than 400 functions in three major
categories: storage, protection, and metabolism. It stores
many minerals and vitamins, such as iron, magnesium, and
the fat-soluble vitamins A, D, E, and K.
• The liver also detoxifies potentially harmful compounds (e.g.,
drugs, chemicals, alcohol). Therefore the risk for drug toxicity
increases with aging because of decreased liver function.

Sherwyn Hatab RN.

 Liver
• The liver functions in the metabolism of proteins considered vital for
human survival. It breaks down amino acids to remove ammonia, which
is then converted to urea and is excreted via the kidneys. In addition, it
synthesizes several plasma proteins, including albumin, prothrombin,
and fibrinogen.
• The liver’s role in carbohydrate metabolism involves storing and
releasing glycogen as the body’s energy requirements change.
• The organ also synthesizes, breaks down, and temporarily stores fatty
acids and triglycerides.

Sherwyn Hatab RN.

Liver
• The liver forms and continually
secretes bile, which is essential
for the breakdown of fat.
• Bile is secreted into small ducts
that empty into the common bile
duct and into the duodenum at
the sphincter of Oddi.
• However, if the sphincter is
closed, the bile goes to the
gallbladder for storage.

Sherwyn Hatab RN.

Gallbladder

• The gallbladder is a pear-shaped, bulbous

sac that is located underneath the liver. It is
drained by the cystic duct, which joins with
the hepatic duct from the liver to form the
common bile duct (CBD).
• The gallbladder collects, concentrates, and
stores the bile that has come from the liver.
It releases the bile into the duodenum via
the CBD when fat is present.

Sherwyn Hatab RN.

Small Intestine

• The small intestine is the

longest and most convoluted
portion of the digestive tract,
measuring 16 to 19 feet (5 to 6
m) in length in an adult.
• It is composed of three
different regions: duodenum,
jejunum, and ileum.

Sherwyn Hatab RN.

Small Intestine
• The small intestine has three main functions: movement (mixing and peristalsis),
digestion, and absorption.
• The intestinal villi (mucous membrane finger like projections) increases the
surface area of the small intestine, it is the major organ of absorption of the
digestive system.
• The small intestine mixes and transports the chyme to mix with many digestive
enzymes. It takes an average of 3 to 10 hours for the contents to be passed by
peristalsis (peristalsis is the involuntary constriction and relaxation of the muscles
of the intestine) through the small intestine. Intestinal enzymes aid in the
digestion of proteins, carbohydrates, and lipids.

Sherwyn Hatab RN.

Large Intestine
• The colon, or large intestine, has a wider
diameter than the small intestine
(approximately 6.0 cm) and is approximately 1.4
m long. It originates in the cecum at RLQ,
where it attaches to the small intestine at the
ileocecal valve.
• At the base of the cecum is the vermiform
appendix, which has no known digestive
function.
• 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.

Sherwyn Hatab RN.

Large Intestine
• The transverse colon runs across the
upper abdomen. In the LUQ 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.

Sherwyn Hatab RN.

Large Intestine

• The colon functions primarily to secrete large amounts of

alkaline mucus to lubricate the intestine and neutralize
acids formed by the intestinal bacteria. Water is also
absorbed through the large intestine, leaving waste
products to be eliminated in stool.

Sherwyn Hatab RN.

 Other Organ
• The urinary bladder, a distensible muscular sac
located behind the pubic bone in the midline of
the abdomen, functions as a temporary
receptacle for urine. A bladder filled with urine
may be palpated in the abdomen above the
symphysis pubis.

Sherwyn Hatab RN.

 Collecting
Subjective Data
• HISTORY OF PRESENT HEALTH CONCERN
• Because GI clinical manifestations are often vague and difficult
for the patient to describe, it is important to obtain a
chronologic account of the current problem, symptoms, and
any treatments taken. Furthermore, ask about the location,
quality, quantity, timing (onset, duration), and factors that
may aggravate or alleviate each symptom.

Sherwyn Hatab RN.

HISTORY OF PRESENT
HEALTH CONCERN
• Abdominal Pain
• Abdominal pain occurs when specific
digestive organs or structures are affected
by chemical or mechanical factors such as
inflammation, infection, distention,
stretching, pressure, obstruction, or
trauma.
• Pain is a common concern of patients with
GI tract disorders. The mnemonic PQRST
may be helpful in organizing the current
problem assessment

Sherwyn Hatab RN.

Pain PQRST
• P: Precipitating or palliative. What brings it on? What makes it better?
What makes it worse?
• Q: Quality. How does it feel, How would you describe the pain?
• R: Region or radiation. Where is it? Does it spread anywhere?
• S: Severity scale. How bad is it (on a scale of 1 to 10)? Is it getting better,
worse, or staying the same?
• T: Timing. Onset—Exactly when did it first occur? Duration—How long
did it last? Frequency—How often does it occur?

Sherwyn Hatab RN.

Abdominal Pain
• How did (does) the pain begin?
• The onset of pain is a diagnostic clue to its origin. For example, acute pancreatitis
produces sudden onset of pain, whereas the pain of pancreatic cancer may be
gradual or recurrent.
• Where is the pain located? Does it move or has it changed from the original
location?
• Location helps to determine the pain source and whether it is primary or referred
• When does the pain occur (timing and relation to particular events such as
eating, exercise, bedtime)?
• Timing and the relationship of particular events may be a clue to origin of pain
(e.g., the pain of a duodenal ulcer may awaken the client at night).
Sherwyn Hatab RN.
Abdominal Pain

• What seems to bring on the pain (precipitating factors), make it worse

(exacerbating factors), or make it better (alleviating factors)?
• Various factors can precipitate or exacerbate abdominal pain such as
alcohol ingestion with pancreatitis or supine position with
gastroesophageal reflux disease. Lifestyle and stress factors may be
implicated in certain digestive disorders such as peptic ulcer disease.
Alleviating factors, such as using antacids or histamine blockers, may
be a clue to origin.
• Antacid and histamine blockers are a group of medicines that reduce
the amount of acid produced by the cells in the lining of the stomach
Sherwyn Hatab RN.
Abdominal Pain

• Is the pain associated with any other symptoms such as nausea,

vomiting, diarrhea, constipation, gas, fever, weight loss, fatigue, or
yellowing of the eyes or skin?
• Associated signs and symptoms may provide diagnostic evidence to
support or rule out a particular origin of pain. For example, epigastric
pain accompanied by tarry stools suggests a gastric or duodenal ulcer.
• tarry stools or black stoold may be due to bleeding in the upper part
of the GI (gastrointestinal) tract, such as the esophagus, stomach, or
the first part of the small intestine.

Sherwyn Hatab RN.

Types of Abdominal Pain
• Visceral pain occurs when hollow abdominal organs, such as the intestines,
become distended or contract forcefully or when the capsules of solid organs
such as the liver and spleen are stretched. Poorly defined or localized and
intermittently timed, this type of pain is often characterized as dull, aching,
burning, cramping, or colicky
• Parietal pain occurs when the parietal peritoneum becomes inflamed, as in
appendicitis or peritonitis. This type of pain tends to localize more to the source
and is characterized as a more severe and steady pain.
• Referred pain occurs at distant sites that are innervated at approximately the
same levels as the disrupted abdominal organ. This type of pain travels, or refers,
from the primary site and becomes highly localized at the distant site.

Sherwyn Hatab RN.

Patterns of Referred Abdominal Pain

Sherwyn Hatab RN.

HISTORY OF PRESENT HEALTH
CONCERN
• Indigestion: DO YOU EXPERIENCE INDIGESTION?
• Indigestion (pyrosis) is a nonspecific term for various symptoms
resulting from a failure of proper digestion and absorption of food
in the alimentary tract.
• It is often described as heartburn, may be an indication of acute or
chronic gastric disorders including hyperacidity, gastroesophageal
reflux disease (GERD), peptic ulcer disease, and stomach cancer.
Take time to determine the client’s exact symptoms because many
clients call gaseousness, belching, bloating, and nausea indigestion.

Sherwyn Hatab RN.

 • Does anything in particular
seem to cause or aggravate
your indigestion?
• Certain factors (e.g., food,
Indigestion drinks, alcohol, medications,
stress) are known to increase
gastric secretion and acidity
and cause or aggravate
indigestion.

Sherwyn Hatab RN.

Nausea
• Do you experience nausea? Describe. Is it triggered by any particular activities,
events, or other factors?
• 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.
• Nausea may also be precipitated by dietary intolerance, psychological triggers, or
menstruation.
• Nausea may also occur at particular times such as early in the day with some
pregnant clients (“morning sickness”), after meals with gastric disorders, or
between meals with changes in blood glucose levels.

Sherwyn Hatab RN.

Vomiting

• Have you been vomiting? Describe the vomitus. Is it associated with

any particular trigger factors?
• Vomiting is associated with impaired gastric motility or reflex
mechanisms. Description of vomitus (emesis) is a clue to the source.
For example, bright hematemesis (vomiting of blood) is seen with
bleeding esophageal varices and ulcers of the stomach or duodenum.
• Clients can easily confuse hematemesis with hemoptysis (coughing up
blood)

Sherwyn Hatab RN.

Appetite

• Have you noticed a change in your appetite? Has this change affected
how much you eat or your normal weight?
• Loss of appetite (anorexia) is a general complaint often associated
with digestive disorders, chronic syndromes, cancers, and
psychological disorders.
• Appetite changes should be carefully correlated with dietary history
and weight monitoring. Significant appetite changes and food intake
may adversely affect the client’s weight and put the client at
additional risk.

Sherwyn Hatab RN.

Bowel Elimination
• Have you experienced a change in bowel elimination patterns? Describe.
• Changes in bowel patterns must be compared to usual patterns for the client.
Normal frequency varies from two to three times per day to three times per week.
• Do you have constipation? Describe. Do you have any accompanying symptoms?
• Constipation is usually defined as a decrease in the frequency of bowel
movements or the passage of hard and possibly painful stools. Signs and
symptoms that accompany constipation may be a clue as to the cause of
constipation such as bleeding with malignancies or pencil-shaped stools with
intestinal obstruction.

Sherwyn Hatab RN.

Bowel Elimination
• Have you experienced diarrhea? Describe. Do you have any accompanying
symptoms?
• Diarrhea is defined as frequency of bowel movements producing unformed or
liquid stools. It is important to compare these stools to the client’s usual bowel
patterns.
• 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. For example,
fever and chills may result from an infection or weight loss and fatigue may result
from a chronic intestinal disorder or a cancer
Sherwyn Hatab RN.
Have you experienced any yellowing of your
skin or whites of your eyes, itchy skin, dark
urine (yellow-brown or tea colored), or clay-
colored stools?

These symptoms should be evaluated to rule

out possible liver disease.

Sherwyn Hatab RN.

Collecting Objective Data
• Preparing the Client:
• Ask the client to empty the bladder before beginning the examination to
eliminate bladder distention because this may interfere with bowel sound
assessment. Instruct the client to remove clothes and to put on a gown. Help
the client to lie supine with the arms folded across the chest or resting by the
sides.
• Instruct the client to breathe through the mouth and to take slow, deep
breaths; this promotes relaxation. Before touching the abdomen, ask the client
about painful or tender areas. These areas should always be assessed at the
end of the examination.

Sherwyn Hatab RN.

 Collecting Objective Data
• The abdomen is assessed by using the four techniques of examination,
but in a sequence different from that used for other body systems:
inspection, auscultation, percussion, and then palpation. This sequence
is preferred so that palpation and percussion do not increase intestinal
activity and bowel sounds.
Sherwyn Hatab RN.
Two positions are appropriate for the abdominal assessment. The client may
lie supine with hands resting on the center of the chest (A) or with arms
resting comfortably at the sides (B). These positions best promote relaxation
of the abdominal muscles.
Sherwyn Hatab RN.
 Assessment
Procedure
• Observe the coloration of the skin.
• Normal Findings:
• Abdominal skin may be paler than the general skin tone
because this skin is so seldom exposed to the natural
elements.

Sherwyn Hatab RN.

Abnormal Skin Coloration Findings

• 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.
• Flank is the right or left side of
a body between the ribs and
the hip.
Sherwyn Hatab RN.
Abnormal Skin Coloration
Findings
• The yellow hue of jaundice may be more
apparent on the abdomen. May indicate liver or
gallbladder disease.

Sherwyn Hatab RN.

Abnormal Skin Coloration
Findings
• Pale, taut skin may be seen with ascites
(significant abdominal swelling indicating fluid
accumulation in the abdominal cavity).
• Ascites usually due to low serum albumin
resulting from from liver failure or liver disease,
liver cirrhosis.
• The liver releases albumin as part of its normal
functioning. Albumin maintains the fluid balance
in the body. It helps prevent the blood vessels
from leaking too much.

Sherwyn Hatab RN.

Abnormal Skin Coloration
Findings
• Redness may indicate
inflammation.

Sherwyn Hatab RN.

Note the vascularity of
the abdominal skin.
• Normal findings
• Scattered fine veins may be visible. Blood in the veins
located above the umbilicus flows toward the head;
blood in the veins located below the umbilicus flows
toward the lower body.

Sherwyn Hatab RN.

Vascularity of the abdominal
skin Abnormal Findings:
• Dilated veins may be seen with cirrhosis of the
liver, obstruction of the inferior vena cava, portal
hypertension, or ascites.
• Cirrhosis also known as liver cirrhosis or hepatic
cirrhosis is an endstage liver disease characterized
by diffuse damage to hepatic parenchymal cells,
and disturbance of normal architecture; associated
with failure in the function of hepatic cells and
interference with blood flow in the liver, frequently
resulting in jaundice, portal hypertension, ascites,
and ultimately biochemical and functional signs of
hepatic failure.
Sherwyn Hatab RN.
 Vascularity of the abdominal
skin Abnormal Findings:

• Dilated surface arterioles and

capillaries with a central star
(spider angioma) may be seen
with liver disease ( common
with Cirrhosis) or portal
hypertension.

Sherwyn Hatab RN.

Note any striae.
• Striae is a stripe or line
distinguished by color, texture,
depression or elevation from the
tissue in which it is found.
• Normal Findings:
• Old, silvery, white striae or
stretch marks from past
pregnancies or weight gain are
normal.

Sherwyn Hatab RN.

Striae Abnormal Findings

• Dark bluish-pink striae are

associated with Cushing’s
syndrome.
• Cushing's syndrome is the
collection of signs and
symptoms due to prolonged
exposure to glucocorticoids
such as cortisol. One of its
symptoms is the dark bluish-
pink striae.
Sherwyn Hatab RN.
Inspect for Scars
• Ask about the source of a scar, and use a
centimeter ruler to measure the scar’s
length. Document the location by
quadrant and reference lines, shape,
length, and any specific characteristics
• (e.g., 3-cm vertical scar in RLQ 4 cm below
the umbilicus and 5 cm left of the midline)
• The photo example is an appendectomy
scar.
• Appendectomy is surgical removal of
appendics.

Sherwyn Hatab RN.

Inspect the umbilicus

• Inspect the umbilicus. Note the

color of the umbilical area.
Observe umbilical location.
• Normal Findings:
• Umbilical skin tones are similar
to surrounding abdominal skin
tones or even pinkish.
Umbilicus is midline at lateral
line.

Sherwyn Hatab RN.

Umbilicus Abnormal
findings
• 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

Sherwyn Hatab RN.

Umbilicus Abnormal findings
• A deviated umbilicus may be caused by pressure from
a mass, enlarged organs, hernia, fluid, or scar tissue
• Deviated means depart from its normal location.
• Hernia (protrusion of the bowel through the
abdominal wall) is seen as a bulging in the abdominal
wall
• The photo above is a case of umbilical hernia
deviating the umbilicus to the right side.
• The photo below is a case of abdominal mass
dieviating the umbilicus to the epigastric region

Sherwyn Hatab RN.

Assess contour of
umbilicus.
• Normal Findings:
• It is recessed (inverted) or
protruding no more than 0.5
cm and is round or conical.
• Abnormal findings:
• An enlarged, everted
umbilicus suggests umbilical
hernia. (Photo )

Sherwyn Hatab RN.

 Inspect abdominal
contour
• Look across the abdomen at eye level
from the client’s side from behind the
client’s head, and from the foot of the
bed. Measure abdominal girth as
indicated.
• Normal Findings:
• Abdomen is flat, rounded, or scaphoid
(usually seen in thin adults) Abdomen
should be evenly rounded.

Sherwyn Hatab RN.

abdominal contour abnormal findings

• A generalized protuberant (protruding) or

distended abdomen may be due to obesity,
air (gas), or fluid accumulation.
• 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 gastric
dilation.
• A scaphoid (sunken) abdomen may be seen
with severe weight loss or cachexia related
to starvation or terminal illness

Sherwyn Hatab RN.

 Observe aortic pulsations.
• Normal Findings:
• A slight pulsation of the abdominal aorta, which is
visible in the epigastrium, extends full length in thin
people.
• Abnormal Findings:
• Vigorous, wide, exaggerated pulsations may be seen
with abdominal aortic aneurysm.
• Abdominal aortic aneurysm is a localized enlargement
of the abdominal aorta such that the diameter is
greater than 3 cm or more than 50% larger than
normal. They usually cause no symptoms, except
during rupture. (illustrated in the 2nd photo)

Sherwyn Hatab RN.

 Auscultate for bowel sounds

• Use the diaphragm of the stethoscope and make sure

that it is warm before you place it on the client’s
abdomen.( to warm the diaphragm of stethoscope
you can hold it in your hands for a few seconds, or rub
in your palm)
• Apply light pressure or simply rest the stethoscope on
a tender abdomen. Begin in the RLQ and proceed
clockwise, covering all quadrants.
• Listen and count 1 full minute per quadrant.
• Confirm bowel sounds in each quadrant. Listen for up
to 5 minute to confirm the absence of bowel sounds. (
you will only auscultate for more than 1 minute if
unable to auscultate a bowel sound in 1 minute)
Sherwyn Hatab RN.
Bowel sound normal
findings
• A series of intermittent, soft clicks and
gurgles are heard at a rate of 5 to 30 per
minute. Hyperactive bowel sounds that
may be heard normally are the loud,
prolonged gurgles characteristic of
stomach growling. These hyperactive
bowel sounds are called “borborygmi.”

Sherwyn Hatab RN.

Bowel sound
abnormal findings
• Hypoactive bowel sounds indicate
diminished bowel motility. Common
causes include abdominal surgery
(normally auscultated after surgery) or late
bowel obstruction.
• hypoactive bowel sounds include a
reduction in the loudness, tone, or
regularity of the sounds.

Sherwyn Hatab RN.

Bowel sound abnormal
findings
• Hyperactive bowel sounds indicate increased bowel
motility. Common causes include diarrhea,
gastroenteritis, or early bowel obstruction.
• hyperactive bowel sounds can sometimes be heard
even without a stethoscope.
• Decreased or absent bowel sounds (again 5 minutes
without bowel sound) signify the absence of bowel
motility, which constitutes an emergency requiring
immediate referral. Absent bowel sounds may be
associated with peritonitis or paralytic ileus

Sherwyn Hatab RN.

Auscultate for vascular
sounds.
• Use the bell of the
stethoscope to listen for
bruits (low-pitched,
murmur like sound) over
the abdominal aorta and
renal, iliac, and femoral
arteries

Sherwyn Hatab RN.

Auscultate for vascular
sounds.
• Normal Findings: Bruits are not normally
heard over abdominal aorta or renal,
iliac, or femoral arteries.
• Abnormal Findings:
• A bruit with both systolic and diastolic
components occurs when blood flow in
an artery is turbulent or obstructed. This
usually indicates aneurysm or arterial
stenosis (narrowing of the artery).

Sherwyn Hatab RN.

 Auscultate for a friction rub
over the liver and spleen.
• Listen over the right and left lower rib cage
with the diaphragm of the stethoscope.
• Friction rubs are rare. If heard, they have a
high-pitched, rough, grating sound
produced when the large surface area of
the liver or spleen rubs the peritoneum.
They are heard in association with
respiration.
• Normal findings: No friction rub over liver or
spleen is present.

Sherwyn Hatab RN.

Auscultate for a friction rub Abnormal result

• A friction rub heard over the

lower right costal area is
associated with hepatic
abscess or metastases.
• A rub heard at the anterior
axillary line in the lower left
costal area is associated with
splenic infarction, abscess,
infection, or tumor.

Sherwyn Hatab RN.

 Percuss for tone

• Lightly and systematically percuss all

quadrants. Two sequences. (the first
photo)
• Normal Findings: Generalized tympany
predominates over the abdomen
because of air in the stomach and
intestines. Normal dullness is heard
over the liver and spleen.
• Dullness may also be elicited over a
nonevacuated descending colon.
Sherwyn Hatab RN.
Perform blunt percussion on the liver

• This is to assess for tenderness in difficult-to-palpate structures. Percuss the

liver by placing your left hand flat against the lower right anterior rib cage. Use
the ulnar side of your right fist to strike your left hand.
• Normally no tenderness is elicited.
• Tenderness elicited over the liver may be associated with inflammation or
infection (e.g., hepatitis or cholecystitis)
• Hepatitis is inflammation of the liver; usually from a viral infection, but
sometimes from toxic agent.
• Cholecystitis is inflammation of the gallbladder

Sherwyn Hatab RN.

blunt percussion on the
kidneys
• Perform blunt percussion on the kidneys at the
costovertebral angles (CVA) over the twelfth rib.
• Normally no tenderness or pain is elicited or
reported by the client.
• Tenderness or sharp pain elicited over the CVA
suggests kidney infection (pyelonephritis), renal
calculi (stone), or hydronephrosis.
• Pyelonephritis is inflammation of the renal
parenchyma particularly due to bacterial
infection.
• Hydronephrosis is dilation of the renal pelvis
resulting to obstruction to urine flow.Sherwyn Hatab RN.
Perform light
palpation
• 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.
• Starting in nontender area To minimize the
client’s voluntary guarding (a tensing or
rigidity of the abdominal muscles usually
involving the entire abdomen).
• Normal findings: Abdomen is nontender
and soft. There is no guarding.

Sherwyn Hatab RN.

Light palpation abnormal findings
• Involuntary reflex guarding is serious and reflects peritoneal
irritation. In involuntary reflex guarding the abdomen is rigid
and fails to relax with palpation when the client exhales. This is
an involuntary response to prevent pain caused by pressure on
abdomen.
• Right-sided guarding may be due to cholecystitis.

Sherwyn Hatab RN.

Deeply palpate all quadrants to delineate
abdominal organs and detect subtle masses

• Using the palmar surface of the fingers, compress to a

maximum depth (5 to 6 cm). Perform bimanual
palpation if you encounter resistance or to assess
deeper structures. (photo: bimanual palpation
perform only if there’s a resistance in deep palpation)
• Normal Findings: Normal (mild) tenderness is possible
over the xiphoid, aorta, cecum, sigmoid colon, and
ovaries with deep palpation.
• Abnormal Findings: Severe tenderness or pain may be
related to trauma, peritonitis, infection, tumors, or
enlarged or diseased organs

Sherwyn Hatab RN.

Deep Palpation
Abnormal Findings
• Palpate for masses.
• Do not confuse a mass with a
normally palpated organ or
structure
• A mass detected in any quadrant
may be due to a tumor, cyst,
abscess, enlarged organ,
aneurysm, or adhesions.

Sherwyn Hatab RN.

 Palpate the liver

• To palpate bimanually, stand at the client’s right side

and place your left hand under the client’s back at the
level of the eleventh to twelfth ribs. Lay your right
hand parallel to the right costal margin (your fingertips
should point toward the client’s head). Ask the client to
inhale then compress upward and inward with your
fingers.
• Note consistency and tenderness.
• Normal Findings: The liver is usually not palpable,
although it may be felt in some thin clients. If the lower
edge is felt, it should be firm, smooth, and even. Mild
tenderness may be normal.

Sherwyn Hatab RN.

Liver Palpation abnormal findings

• A hard, firm liver may indicate cancer. Nodularity may occur with
tumors, metastatic cancer, late cirrhosis, or syphilis. Tenderness may
be from vascular engorgement (e.g., congestive heart failure), acute
hepatitis, or abscess.
• Syphilis is a bacterial infection usually spread by sexual contact.
• Vascular engorgement ( blood vessels are full and hard usually due to
congestive heart failure)
• Abscess is a swollen area within body tissue, containing an
accumulation of pus.

Sherwyn Hatab RN.

Palpate the spleen.

• Stand at the client’s right side, reach over

the abdomen with your left arm, and place
your hand under the posterior lower ribs.
Pull up gently. Place your right hand below
the left costal margin with the fingers
pointing toward the client’s head. Ask the
client to inhale and press inward and
upward as you provide support with your
other hand.
• Normal findings: The spleen is seldom
palpable at the left costal margin. If the
edge of the spleen can be palpated, it
should be soft and nontender.

Sherwyn Hatab RN.

Spleen palpation abnormal findings

• Palpable spleen suggests

enlargement (up to three times the
normal size), which may result from
trauma, mononucleosis, chronic
blood disorders (hemolytic anemia.
Leukemia), and cancers.
• Mononucleosis is an abnormally
high proportion of monocytes (a
large phagocytic white blood cell) in
the blood.

Sherwyn Hatab RN.

Palpate the urinary bladder

• Palpate for a distended bladder when the

client’s history or other findings warrant
(e.g., dull percussion noted over the
symphysis pubis). Begin at the symphysis
pubis and move upward and outward to
estimate bladder borders.
• Normally the bladder is not palpable.
• A distended bladder is palpated as a
smooth, round, and somewhat firm mass
extending as far as the umbilicus. It may be
further validated by dull percussion tones.

Sherwyn Hatab RN.

Tests for Appendicitis Palpating deeply

• Appendicitis is inflammation of the appendix

• Assess for rebound tenderness.
• Abdominal pain and tenderness may indicate
peritoneal irritation. To assess this possibility, test
for rebound tenderness. Palpate deeply in the
abdomen where the client has pain then suddenly
release pressure. Listen and watch for the client’s Releasing
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.
• Normal finding: No rebound tenderness is present

Sherwyn Hatab RN.

Rebound tenderness assessment video

Sherwyn Hatab RN.

Rebound tenderness abnormal findings

• The client has rebound tenderness when he or she perceives sharp,

stabbing pain as the examiner releases pressure from the abdomen
(Blumberg’s sign). It suggests peritoneal irritation (as from
appendicitis).
• If the client feels pain at an area other than where you were assessing
for rebound tenderness, consider that area as the source of the pain
(see test for referred rebound tenderness, in next slide).

Sherwyn Hatab RN.

Assess for Rovsing’s Sign

• Test for referred rebound

tenderness
• Palpate deeply in the LLQ and,
quickly release pressure.
• Abnormal findings: No rebound
pain is elicited
• Abnormal findings: Pain in the
RLQ during pressure in the LLQ is a
positive Rovsing’s sign. It suggests
acute appendicitis
Sherwyn Hatab RN.
Rovsing’s Sign Video

Sherwyn Hatab RN.

Test for Cholecystitis

• Assess RUQ pain or tenderness, which may signal cholecystitis

(inflammation of the gallbladder). Press your fingertips under the liver
border at the right costal margin and ask the client to inhale deeply.
• Normal findings: No increase in pain is present.
• Abnormal Findings: Accentuated sharp pain that causes the client to
hold his or her breath (inspiratory arrest) is a positive Murphy’s sign
and is associated with acute cholecystitis.

Sherwyn Hatab RN.

Test for Murphy’s Sign Video (click at the center of the slide)

Sherwyn Hatab RN.

Appendicitis
• The inflammation of the
vermiform appendix, the
common cause is an
obstruction of the intestinal
lumen from infection, fecal
mass, foreign body or tumor.
• It is the most common cause of
right lower quadrant (RLQ)
pain.

Sherwyn Hatab RN.

Appendicitis
• Inflammation occurs when the lumen (opening) of the appendix is obstructed
(blocked), leading to infection as bacteria invade the wall of the appendix. The
initial obstruction is usually a result of fecaliths (very hard pieces of feces)
composed of calcium phosphate–rich mucus and inorganic salts. Less common
causes are malignant tumors, helminthes (worms), or other infections.
• When the lumen is blocked, the mucosa secretes fluid, increasing the internal
pressure and restricting blood flow, resulting in pain. If the process occurs slowly,
an abscess may develop, but a rapid process may result in peritonitis
(inflammation of the peritoneum).
• All complications of peritonitis are serious. Gangrene can occur within 24 to 36
hours, is life threatening, and is one of the most common indications for
emergency surgery. Perforation may develop within 24 hours, but the risk rises
rapidly after 48 hours

Sherwyn Hatab RN.

 Clinical Manifestations

• Abdominal pain
• Local tenderness at Mc Burney’s point
• Rovsing’s sign
• Rebound terderness
• Mild fever
• Nausea and vomiting
• Anorexia, moderate malaise
• moderate elevation of the white blood cell
(WBC) count (leukocytosis) to 10,000 to
18,000/mm3.
• 20,000/mm3 may indicate a perforated/ruptured
appendix.
Sherwyn Hatab RN.
Acute Cholecystitis
• The most common type is
calculous cholecystitis, in which
chemical irritation and
inflammation result from
gallstones (cholelithiasis) that
obstruct the cystic duct (most
often), gallbladder neck, or
common bile duct
(choledocholithiasis), with
common bile duct obstruction
client may manifest jaundice.
Sherwyn Hatab RN.
 Acute
Cholecystitis
• When the gallbladder is inflamed, trapped bile is reabsorbed
and acts as a chemical irritant to the gallbladder wall; that is,
the bile has a toxic effect. Reabsorbed bile, in combination
with impaired circulation, edema, and distention of the
gallbladder, causes ischemia and infection. The result is tissue
sloughing with necrosis and gangrene. The gallbladder wall
may eventually perforate (rupture).

Sherwyn Hatab RN.

 Women

Aging

Obesity
Risk Factors Rapid weight loss or
for prolonged fasting
Cholecystitis
Increased serum cholesterol

Cholesterol-lowering drugs

Family history of gallstones

Sherwyn Hatab RN.

 Clinical Manifestations
• Episodic upper abdominal pain or discomfort that can
radiate to the right shoulder
• Pain triggered by a high-fat or high-volume meal
• Anorexia
• Nausea and/or vomiting
• Indigestion
• Flatulence (gas)
• Feeling of abdominal fullness
• Rebound tenderness (Blumberg’s sign) in RUQ
• Fever
• Jaundice, clay-colored stools, dark urine, steatorrhea (most
common with chronic cholecystitis)
Sherwyn Hatab RN.
I’m grateful to be part of your nursing education…
see you next school year… SherwynHatab
Sherwyn Hatab RN.