1
Q
Inspecting the contour of the abdomen
A
- Stand on persons right side and look down the abdomen. Determine profile from the rib margin to the pubic bone. COntour describes nutritional state and ranges from flat-round.
- flat, scaphiod (caves in, below level of hip bone), rounded, protuberant.
2
Q
Inspect symmetry of abdomen
A
Shine light across abdomen toward you or lengthwise across person. Have them take a deep breath to further highlight changes. May also ask them to do a sit-up without using their hands (this may show hernia or enlarged liver or spleen).
Normal= “abdomen is symmetrical, smooth, bilaterally)
Abnormal=Note any bulging, masses, or asymmetrical shape. Hernias are protrusion of the abdominal viscera through an opening in muscle wall.
3
Q
Inspect umbilicus
A
Normal= “umbilicus is midline and inverted with no discoloration, inflammation, or hernia. If pregnant, it everts.
Abnormal:
-Everted=ascites or underlying mass.
- Deeply sunken= obesity
- enlarged, everted= umbilical hernia
-bluish periumbilical color with intra-abdominal bleeding (Cullen sign)
4
Q
inspect skin of abdomen- Normal Findings
A
Normal= “skin is smooth and even, with homogenous color”
*good area to judge pigment of skin since it is covered from sun.
-Striae: Common pigment change that is silvery white, linear, jagged marks about 1-6 cm long. Occur when elastic fibers in the reticular layer of skin and broken after rapid, prolonged stretching (pregnancy, excessive weight gain). They start out as pink or blue and turn silverish.
*purple/blue straie are abnormal- cushings
- Pigmented nevi may be present
-scars may be present
-Veins are usually not seen.
Good skin turgor reflects healthy nutrition (check turgor)
5
Q
What do you do when inspecting skin and a scar is present ?
A
Draw its location in the persons record, and indicate the length in cm. Ask about the scar and if it is from surgery. A surgical scar alerts you to possible presence of underlying adhesions and excess fibrous tissue.
6
Q
Abnormalities inspecting skin color
A
Color Abnormalities:
- Redness with localized inflammation
- Jaundice (best in natural light)
- Skin that is glistening and taut is sign of ascites
7
Q
Abnormalities inspecting skin of abdomen–abnormal striae
A
- striae occurs with ascites
- purple/blue striae with Cushings (excess ACTH)
8
Q
Inspecting skin of abdormen- abnormal lesions
A
- any unusual change in color or shape
- Petechiae
- Cutaneous anginomas (spider nevi) occur with portal hypertension or liver disease
- lesions or rashes
- underlying adhesions are inflammatory bands that connect opposite sides of serous surfaces after trauma or surgery
9
Q
Inspecting skin of abdomen- Abnormal veins
A
Prominent, dilated veins occur with portal hypertension, cirrhosis, ascites, or vena caval obstruction. Veins are more visible with malnutrition as a result of thinned adipose tissue.
10
Q
inspecting skin of abdomen- abnormal turgor
A
poor turgor occurs with dehydration, which often accompanies GI disease
11
Q
Inspecting abdomen pulsation and movement- Normal
A
Normally see pulsation of aorta beneath skin in the epigastric area, particularly in those with good muscle wall relaxation.
- normally see respirations especially in males
- normally see waves of peristalsis in very thin people
12
Q
Inspecting pulsation and movement- abnormal findings
A
- Marked pulsations of aorta occurs with widened pulse pressure ( hypertension, aortic insufficiency, thyrotoxicosis), and aortic aneurysm
- marked visible peristalsis together with distended abdomen indicated intestinal obstruction
13
Q
abnormal/altered hair distribution occurs with?
A
endocrine or hormone abnormalities, and chronic liver disease
14
Q
Normal Demeanor
A
relaxed, quietly on table and has benign facial expression and slow even respirations
15
Q
Abnormal demeanor
A
- restlessness and constant turning to find comfort- colickly pain of gastroenteritis or bowel obstruction
- Absolute stillness, resisting any movement occurs with pain of peritonitis
- knees flexed up, facial grimicaing, and rapid, uneven respirations also indicate paine
16
Q
Procedure for auscultating bowel sounds
A
- Auscultation after inspection and before paplation or percussion.
- use diaphragm and hold lightly against skin
- begin in RLQ at ileocecal valve because bowel sounds are normally always present there
17
Q
Normal findings when auscultating bowel sounds
A
- Note the character and frequency of bowel sounds
- bowel sounds are high pitched, gurgling, cascading sounds, occuring irregularly anywhere from 5-30 per min. Dont count them. Just note if they are normal, hypoactive or hyperactive.
- Normal hyperactive bowl sound is borborgymus (stomach growling)
18
Q
Completely absent bowel sounds
A
uncommon. must listen for 5 min before deciding bowel sounds are completely absent.
19
Q
Abnormal Bowel Sounds (hyperactive & hypoactive)
A
- Hyperactive: loud, high pitch, rushing, tinkling sounds that signal increase motility
- Hypoactive or absent: follow abdominal surgery or with inflammation or peritoneum
20
Q
Auscultating Vascular sounds- Normal findings
A
- Listen for bruits using firmer pressure
- check over aorta, renal arteries, iliac, femoral arteries (ESPECIALLY in people with hypertension!)
- Bruits should not be present UNLESS it is a healthy person who is younger than 40 yrs, and the sound originates from celiac artery. (sound is systolic, medium to low pitch, and heard between xiphoid process and umbilicus_
21
Q
Auscultating vascular sounds- abnormal findings
A
If vascular sound is found, note the location, pitch and timing.
- systolic bruit is a pulsatile blowing sound and occurs with stenosis or occlusion of artery
- venous hum and peritoneal friction rub are rare
22
Q
Percussing for tympany in all 4 Q- Abnormal findings
A
- Dullness occurs over distended bladder, adipose tissue, fluid, or mass.
- Hyperresonance with gaseous distention
23
Q
Percussing liver span
A
Measure the height of the liver in the right midclavicular line.
- the liver span usually is underestimated because of inaccurate detection of the upper border.
- Begin in the area of lung resonance, and percuss down the interspaces until the sound changes to a dull quality Mark the spot, usually in the fifth intercostal space. Then find abdominal tympany and percuss up in the midclavicular line. Mark where sound changes from tympany to a dull sound, normally at the right costal margin.
- Measure the distance between the two marks; the normal liver span in the adult ranges from 6 to 12cm
- height of the liver span correlates with the height of the person; taller people have longer livers. - males have a larger liver span than females of the same height.
- mean liver span is 10.5cm for males and 7cm for females.
24
Q
Percussing liver span- abnormal findings
A
-An enlarged liver span indicates liver enlargement or hepatomegaly.
- Accurate detection of liver borders is confused by dullness above the fifth intercostal space, which occurs with lung disease (e.g., pleural effusion or consolidation).
- Accurate detection at the lower border is confused when dullness is pushed up with ascites or pregnancy or with gas distention in the colon, which obscures the lower border.
25
Liver span in emphysema patients
One variation occurs in people with chronic emphysema, in which the liver is displaced downward by the hyperinflated lungs. Although you hear a dull percussion note well below the right costal margin, the overall span is still within normal limits.
26
The Scratch Test for liver border
Although traditionally taught, this technique does not work to identify the liver border. It uses a repeated scratching sound from your fingernail along the patient's abdomen; when the sound is magnified in the stethoscope, it was thought to define the lower liver border. However, evidence shows no correlation whatsoever between the liver edge by auscultation of scratches and the actual liver edge by ultrasound
27
Percussing for Spenic Dullness
Often the spleen is obscured by stomach contents, but you may locate it by percussing for a dull note from the ninth to eleventh intercostal space just behind the left midaxillary line
- The area of splenic dullness normally is not wider than 7 cm in the adult and should not encroach on the normal tympany over the gastric air bubble.
- Next, percuss in the lowest interspace in the left anterior axillary line. Should hear tympany Ask the person to take a deep breath. Normally, tympany remains through full inspiration.
28
Abnormal Splenic dullness
- A dull note forward of the midaxillary line indicates enlargement of the spleen, as occurs with mononucleosis, trauma, and infection.
- When percussing anterior axillary line, a change in percussion from tympany to a dull sound with full inspiration is a POSITIVE SPLEEN PERCUSSION SIGN, indicating splenomegaly. This method will detect mild to moderate splenomegaly before the spleen becomes palpable, as in mononucleosis, malaria, or hepatic cirrhosis.
29
Percuss for Costovertebral Angle Tenderness
ndirect fist percussion causes the tissues to vibrate instead of producing a sound. To assess the kidney, place one hand over the twelfth rib at the costovertebral angle on the back (Fig. 21-17). Thump that hand with the ulnar edge of your other fist. The person normally feels a thud but no pain. (Although this step is explained here with percussion techniques, its usual sequence in a complete examination is with thoracic assessment, when the person is sitting up and you are standing behind.)
*ABNORMAL FINDING= Sharp pain occurs with inflammation of the kidney or paranephric area.
30
How do you determine is person has Ascites?
- distended abdomen, bulging flanks, umbilicus that is protruding and displaced downward. Do these test to differentiate ascites from gaseous distention:
- Fluid wave test
- Shifting Dullness test
31
Fluid Wave test
- Stand on the person's right side. Place the ulnar edge of hand or the patient's own hand firmly on the abdomen in the midline (This will stop transmission across the skin of the upcoming tap.) - Place your left hand on the person's right flank. With your right hand, reach across the abdomen and give the left flank a firm strike.
- If ascites is present, fluid wave through the abdomen and you will feel a distinct tap on your left hand. If the abdomen is distended from gas or adipose tissue, you will feel no change.
* Positive fluid wave test occurs with large amounts of ascitic fluid.
32
Shifting dullness
- In a supine person, ascitic fluid settles by gravity into the flanks, displacing the air-filled bowel upward. You will hear a tympanitic note as you percuss over the top of the abdomen because gas-filled intestines float over the fluid). Then percuss down the side of the abdomen.
* If fluid is present, the note will change from tympany to dull as you reach its level. Mark this spot.
- Now turn the person onto the right side (roll the person toward you). The fluid will gravitate to the dependent (in this case, right) side, displacing the lighter bowel upward. Begin percussing the upper side of the abdomen and move downward. The sound changes from tympany to a dull sound as you reach the fluid level, but this time the level of dullness is higher, upward toward the umbilicus. - - This shifting level of dullness indicates the presence of fluid.
* Shifting dullness is positive with a large volume of ascitic fluid: it will not detect less than 500 mL of fluid.
33
Procedure for palpating
1 Bend the person's knees.
2 Keep your palpating hand low and parallel to the abdomen. Holding the hand high and pointing down would make anyone tense up.
3 Teach the person to breathe slowly (in through the nose, and out through the mouth).
4 Keep your own voice low and soothing. Conversation may relax the person.
5 Try “emotive imagery.” For example, you might say, “Now I want you to imagine you are dozing on the beach, with the sun warming your muscles and the sound of the waves lulling you to sleep. Let yourself relax.”
6 With a very ticklish person, keep the person's hand under your own with your fingers curled over his or her fingers. Move both hands around as you palpate; people are not ticklish to themselves.
7 Alternatively, perform palpation just after auscultation. Keep the stethoscope in place and curl your fingers around it, palpating as you pretend to auscultate. People do not perceive a stethoscope as a ticklish object. You can slide the stethoscope out when the person is used to being touched.
34
Light Palpation
With the first four fingers. depress the skin about 1 cm. Then lift the fingers (do not drag them) and move clockwise to the next location around the abdomen.
- Do not search for organs but form an overall impression of the skin surface and superficial musculature. Save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination.
35
Voluntary gaurding during light palpation
As you circle the abdomen, discriminate between voluntary muscle guarding and involuntary rigidity. Voluntary guarding occurs when the person is cold, tense, or ticklish. It is bilateral, and you will feel the muscles relax slightly during exhalation. Use the relaxation measures to try to eliminate this type of guarding, or it will interfere with deep palpation. If the rigidity persists, it is probably involuntary.
36
Abnormalities during light palpation
Muscle guarding.
Rigidity.
Large masses.
Tenderness
37
Involuntary rigidity during light palpation
Involuntary rigidity is a constant, boardlike hardness of the muscles. It is a protective mechanism accompanying acute inflammation of the peritoneum. It may be unilateral, and the same area usually becomes painful when the person increases intra-abdominal pressure by attempting a sit-up.
38
Deep Palpation
push down about 5 to 8 cm (2 to 3 inches) (Fig. 21-22). Moving clockwise, explore the entire abdomen.
- To overcome the resistance of a very large or obese abdomen, use a bimanual technique.
- Note the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses.
39
Normally Palpable structures
- Xiphiod Process
- Normal liver edge
- Right kidney, lower pole
- Pulsatile aorta
- rectus muscles, lateral borders
- Sacral promontory
- ascending colon
- cecum
- sigmoid colon
- uterus
- full bladder
40
Sigmoid colon
Normally, mild tenderness during palpation. Investigate any other tenderness.
41
Tenderness during palpation occurs with ?
Tenderness occurs with local inflammation, with inflammation of the peritoneum or underlying organ, and with an enlarged organ whose capsule is stretched.
42
If you identify a mass, first distinguish it from a normally palpable structure or an enlarged organ. Then note the following:
```
1 Location
2 Size
3 Shape
4 Consistency (soft, firm, hard)
5 Surface (smooth, nodular)
6 Mobility (including movement with respirations)
7 Pulsatility
8 Tenderness
```
43
Normal palpation of liver
RUQ (Fig. 21-25). Place your left hand under the person's back parallel to the eleventh and twelfth ribs and lift up to support the abdominal contents. Place your right hand on the RUQ, with fingers parallel to the midline. Push deeply down and under the right costal margin. Ask the person to breathe slowly. With every exhalation, move your palpating hand up 1 or 2 cm. It is normal to feel the edge of the liver bump your fingertips as the diaphragm pushes it down during inhalation. It feels like a firm, regular ridge. Often, the liver is not palpable and you feel nothing firm.
44
Abnormal Palpation of liver
Except with a depressed diaphragm, a liver palpated more than 1 to 2 cm below the right costal margin is enlarged. Record the number of centimeters it descends and note its consistency (hard, nodular) and tenderness
45
Is the spleen normally palpable?
Normally, the spleen is not palpable and must be enlarged three times its normal size to be felt. To search for it, reach your left hand over the abdomen and behind the left side at the eleventh and twelfth ribs (Fig. 21-27, A). Lift up for support. Place your right hand obliquely on the LUQ with the fingers pointing toward the left axilla and just inferior to the rib margin. Push your hand deeply down and under the left costal margin and ask the person to take a deep breath. You should feel nothing firm.
46
If the spleen is palpable, what could it mean?
The spleen enlarges with mononucleosis, trauma, leukemias, and lymphomas (see Table 21-6). If you feel an enlarged spleen, refer the person but do not continue to palpate it. An enlarged spleen is friable and can rupture easily with overpalpation.
Describe the number of centimeters it extends below the left costal margin.
- When enlarged, the spleen slides out and bumps your fingertips. It can grow so large that it extends into the lower quadrants. When this condition is suspected, start low so you will not miss it. An alternative position is to roll the person onto his or her right side to displace the spleen more forward and downward. Then palpate.
47
Palpating for Kidneys
Search for the right kidney using “duck-bill” position at the person's right flank. Press your two hands together firmly (you need deeper palpation than that used with the liver or spleen) and ask the person to take a deep breath. In most people, you will feel no change. Occasionally, you may feel the lower pole of the right kidney as a round, smooth mass slide between your fingers. Either condition is normal.
The left kidney sits 1 cm higher than the right kidney and is not palpable normally. Search for it by reaching your left hand across the abdomen and behind the left flank for support. Push your right hand deep into the abdomen and ask the person to breathe deeply. You should feel no change with the inhalation.
48
Palpating for Aorta
Using your opposing thumb and fingers, palpate the aortic pulsation in the upper abdomen slightly to the left of midline (Fig. 21-29). Normally, it is 2.5 to 4 cm wide in the adult and pulsates in an anterior direction.
*Abnormal Aorta= Widened with aneurysm.
Prominent lateral pulsation with aortic aneurysm pushes the examiner's two fingers apart.
49
Rebound Tenderness (Blumberg Sign)
Assess rebound tenderness when the person reports abdominal pain or when you elicit tenderness during palpation. Choose a site away from the painful area. Hold your hand 90 degrees, or perpendicular, to the abdomen. Push down slowly and deeply, then lift up quickly.
This makes structures that are indented by palpation rebound suddenly. A normal, or negative, response is no pain on release of pressure. Perform this test at the end of the examination, because it can cause severe pain and muscle rigidity.
50
Abnormal finding of rebound tenderness/blumberg sign
Pain on release of pressure confirms rebound tenderness, which is a reliable sign of peritoneal inflammation. Peritoneal inflammation accompanies appendicitis.
Cough tenderness that is localized to a specific spot also signals peritoneal irritation. Refer the person with suspected appendicitis for computed tomography (CT) scanning.
51
Inspiratory Arrest (Murphy Sign)
Normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder (cholecystitis), pain occurs. Hold your fingers under the liver border. Ask the person to take a deep breath. A normal response is to complete the deep breath without pain. (Note: This sign is less accurate in patients older than 60 years; evidence shows that 25% of them do not have any abdominal tenderness)
52
Positive/abnormal murphy sign
When the test is positive, as the descending liver pushes the inflamed gallbladder onto the examining hand, the person feels sharp pain and abruptly stops inspiration midway.
53
Iliopsoas Muscle Test
Perform the iliopsoas muscle test when the acute abdominal pain of appendicitis is suspected. With the person supine, lift the right leg straight up, flexing at the hip, then push down over the lower part of the right thigh as the person tries to hold the leg up. When the test is negative, the person feels no change. (Note: Evidence shows that the Obturator Test, another technique that stretches the obturator muscle, does not work to diagnose appendicitis)
54
Abnormal lliopsoas muscle test
When the iliopsoas muscle is inflamed (which occurs with an inflamed or perforated appendix), pain is felt in the right lower quadrant.
55
Normal findings in the aging adult
On inspection, you may note increased deposits of subcutaneous fat on the abdomen and hips because it is redistributed away from the extremities. The abdominal musculature is thinner and has less tone than that of the younger adult; thus, in the absence of obesity, you may note peristalsis.
Because of the thinner, softer abdominal wall, the organs may be easier to palpate (in the absence of obesity). The liver is easier to palpate. Normally, you will feel the liver edge at or just below the costal margin. With distended lungs and a depressed diaphragm, the liver is palpated lower, descending 1 to 2 cm below the costal margin with inhalation. The kidneys are easier to palpate.
56
abnormal findings in the aging adult
Abdominal rigidity with acute abdominal conditions is less common in aging.
With an acute abdomen, the aging person often complains of less pain than a younger person would.
57
The nurse is percussing the seventh right intercostal space at the midclavicular line over the liver. Which sound should the nurse expect to hear?
A) Dullness
B) Tympany
C) Resonance
D) Hyperresonance
Dullness
Page: 541. The liver is located in the right upper quadrant and would elicit a dull percussion note.
58
Which structure is located in the left lower quadrant of the abdomen?
A) Liver
B) Duodenum
C) Gallbladder
D) Sigmoid colon
Sigmoid colon
Page: 530. The sigmoid colon is located in the left lower quadrant of the abdomen.
59
The nurse suspects that a patient has a distended bladder. How should the nurse assess for this condition?
A) Percuss and palpate in the lumbar region.
B) Inspect and palpate in the epigastric region.
C) Auscultate and percuss in the inguinal region.
D) Percuss and palpate the midline area above the suprapubic bone.
D) Percuss and palpate the midline area above the suprapubic bone.
Pages: 539-540. Dull percussion sounds would be elicited over a distended bladder, and the hypogastric area would seem firm to palpation.
60
While examining a patient, the nurse observes abdominal pulsations between the xiphoid and umbilicus. The nurse would suspect that these are:
A) pulsations of the renal arteries.
B) pulsations of the inferior vena cava.
C) normal abdominal aortic pulsations.
D) increased peristalsis from a bowel obstruction.
normal abdominal aortic pulsations.
Pages: 538-539. Normally, one may see the pulsations from the aorta beneath the skin in the epigastric area, particularly in thin persons with good muscle wall relaxation.
61
A patient has hypoactive bowel sounds. The nurse knows that a potential cause of hypoactive bowel sounds is:
A) diarrhea.
B) peritonitis.
C) laxative use.
D) gastroenteritis.
B) peritonitis.
Page: 561. Diminished or absent bowel sounds signal decreased motility from inflammation as seen with peritonitis, with paralytic ileus after abdominal surgery, or with late bowel obstruction.
62
The physician comments that a patient has abdominal borborygmi. The nurse knows that this term refers to:
A) a loud continuous hum.
B) a peritoneal friction rub.
C) hypoactive bowel sounds.
D) hyperactive bowel sounds.
hyperactive bowel sounds.
Pages: 539-540. Borborygmi is the term used for hyperperistalsis when the person actually feels his or her stomach growling.
63
During an abdominal assessment, the nurse would consider which of these findings as normal?
A) The presence of a bruit in the femoral area
B) A tympanic percussion note in the umbilical region
C) A palpable spleen between the ninth and eleventh ribs in the left midaxillary line
D) A dull percussion note in the left upper quadrant at the midclavicular line
A tympanic percussion note in the umbilical region
Pages: 539-540. Tympany should predominate in all four quadrants of the abdomen because air in the intestines rises to the surface when the person is supine. Vascular bruits are not usually present. Normally the spleen is not palpable. Dullness would not be found in the area of lung resonance (left upper quadrant at the midclavicular line).
64
. During an abdominal assessment, the nurse is unable to hear bowel sounds in a patient's abdomen. Before reporting this finding as "silent bowel sounds" the nurse should listen for at least:
A) 1 minute.
B) 5 minutes.
C) 10 minutes.
D) 2 minutes in each quadrant
5 minutes.
Pages: 539-540. Absent bowel sounds are rare. The nurse must listen for 5 minutes before deciding bowel sounds are completely absent.
65
A patient is suspected of having inflammation of the gallbladder, or cholecystitis. The nurse should conduct which of these techniques to assess for this condition?
A) Obturator test
B) Test for Murphy's sign
C) Assess for rebound tenderness
D) Iliopsoas muscle test
Test for Murphy's sign
Page: 551. Normally, palpating the liver causes no pain. In a person with inflammation of the gallbladder, or cholecystitis, pain occurs as the descending liver pushes the inflamed gallbladder onto the examining hand during inspiration (Murphy's test). The person feels sharp pain and abruptly stops inspiration midway.
66
During an assessment the nurse notices that a patient's umbilicus is enlarged and everted. It is midline, and there is no change in skin color. The nurse recognizes that the patient may have which condition?
A) Intra-abdominal bleeding
B) Constipation
C) Umbilical hernia
D) An abdominal tumor
C) Umbilical hernia
Page: 537. The umbilicus is normally midline and inverted, with no signs of discoloration. With an umbilical hernia, the mass is enlarged and everted. The other responses are incorrect.
67
The nurse suspects that a patient has appendicitis. Which of these procedures are appropriate for use when assessing for appendicitis or a perforated appendix? Select all that apply.
```
A) Test for Murphy's sign.
B) Test for Blumberg's sign.
C) Test for shifting dullness.
D) Perform iliopsoas muscle test.
E) Test for fluid wave.
```
B) Test for Blumberg's sign.
D) Perform iliopsoas muscle test.
Pages: 543-544 | Page: 551. Testing for Blumberg's sign (rebound tenderness) and performing the iliopsoas muscle test should be used to assess for appendicitis. Murphy's sign is used to assess for an inflamed gallbladder or cholecystitis. Testing for a fluid wave and shifting dullness is done to assess for ascites.
Assessment: Abdomen
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