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17-2 Key Points Ball: Seidel’s Guide to Physical Examination, 8th Edition Chapter 17: Abdomen Key Points This review discusses examination of the abdomen. Before the exam, gather the necessary equipment : stethoscope, centimeter ruler, non-stretch tape measure, and marking pen. To inspect the abdomen, perform the following. Using tangential lighting, inspect the abdomen for four surface characteristics . First, observe the skin color .
It may vary greatly but should have no jaundice, cyanosis, redness, bruises, or discoloration. Second, check for nodules and other lesions , which should not be present. Third, note any scars and draw their location, configuration, and relative size on an illustration of the abdomen. Fourth, assess the venous return . Above the umbilicus, venous return should be toward the head.
Below the umbilicus, it should be toward the feet. Next, inspect the abdominal contour and symmetry . The contour is the abdominal profile from the rib margin to the pubis. It normally may be flat, rounded, or scaphoid. The umbilicus should be centrally located and may be inverted or may protrude slightly.
Contralateral areas of the abdomen should be symmetrical in appearance and contour and should have no distention or bulges. To elicit hidden masses or bulges , have the patient take a deep breath and hold it. The abdomen should remain smooth and symmetrical. Next, have the supine patient raise their head from the table as you inspect the abdomen. Note any masses, hernia, or muscle separation.
With the patient’s head at rest, observe for three types of abdominal movement . First, inspect for smooth, even movement with respiration . Second, assess for surface motion from peristalsis . In a thin patient, it normally may be visible. Otherwise, it may signal an intestinal obstruction.
Third, note any aortic pulsation in the upper midline . Although pulsations may be visible in a thin patient, marked pulsations suggest a disorder. To auscultate the abdomen, perform the following. Remember to auscultate before you percuss or palpate because these techniques can alter bowel sounds. Using the diaphragm of a warmed stethoscope, listen for bowel sounds and note their frequency and character.
Expect to hear clicks and gurgles at a rate of 5 to 35 per minute. Note unexpected findings , such as increased or decreased bowel sounds or high-pitched tinkling sounds. Auscultate for three additional sounds . First, use the stethoscope diaphragm to detect high-pitched friction rubs over the liver and spleen. Second, use the stethoscope bell to check for bruits over the aortic, renal, iliac, and femoral arteries.
Third, use the stethoscope bell to assess for a soft, continuous, low-pitched venous hum in the epigastric area and around the umbilicus. To percuss the abdomen, perform the following. Systematically percuss for tone in all abdominal quadrants. Tympany is heard over the stomach and intestines. Dullness is heard over organs and solid masses.
Percuss to estimate the liver span , using three steps. First, determine the lower border of the liver by percussing up from an area of tympany along the right midclavicular line. Mark the point where tympany changes to dullness, which usually occurs at or slightly below the costal margin. Second, determine the upper border of the liver by percussing down from an area of resonance along the right midclavicular line. Mark the point where resonance changes to dullness, which usually is in the fifth intercostal space.
Third, measure the distance between the marks. The vertical liver span usually ranges from 6 to 12 cm. To assess liver descent , ask the patient to take a deep breath and hold it while you percuss the lower border again. With this maneuver, the area of dullness at the lower border should shift down 2 to 3 cm. Percuss the spleen just posterior to the midaxillary line on the left side, beginning in areas of lung resonance and moving in several directions.
You normally may hear a small area of splenic dullness from the sixth to ninth rib. Percuss the lowest intercostal space in the left anterior axillary line before and after the patient takes a deep breath. Tympany should remain in this area. Percuss for the gastric air bubble in the left lower anterior rib cage and left epigastric region. Gastric bubble tympany is lower in pitch than intestinal tympany.
With the patient seated, percuss the kidneys , following two steps. First, place the palm of your hand over the right costovertebral angle and strike it with the side of the fist of your other hand. Second, repeat this action on the left costovertebral angle . In both locations, the patient should feel a thud but no pain. To palpate the abdomen, perform the following.
Using light palpation , systematically assess all quadrants. But first, try to relax the abdominal muscles. For example, place a small pillow under the patient’s head and slightly flexed knees, warm your hands, take a slow and gentle approach, and save any tender areas for last. For light palpation, press in no more than 1 cm with the palmar surface of your fingers. Expect the abdomen to feel smooth and soft.
Note any resistance or tenderness . And watch for guarding, which should alert you to proceed with caution. Using moderate palpation , systematically assess all quadrants in two ways. First, palpate with the palmar surface of your fingers . This may elicit tenderness that was not produced by light palpation.
Second, palpate with the side of your hand throughout the respiratory cycle. As the patient inhales, you may feel the liver and spleen bump gently against your hand. Using deep palpation , systematically assess all quadrants with the palmar surface of your fingers. If a patient’s obesity or muscular resistance makes deep palpation difficult, try bimanual palpation with one hand on top of the other. With either technique, feel for the rectus abdominis muscles, aorta, and portions of the colon.
Note any tenderness. If you detect a mass, evaluate its location, size, shape, consistency, tenderness, pulsation, mobility, and movement with respiration. To see if the mass is superficial or intraabdominal, palpate as the patient lifts his or her head off the table. A superficial mass will remain palpable; an intraabdominal mass will not. Palpate the umbilical ring and periumbilical area .
The umbilical ring should feel round and regular. The area should have no bulges, nodules, or granulation. Palpate for specific abdominal structures . For the liver , press in and feel for its edge at the right costal margin as the patient takes a deep breath. If palpable, the liver should feel firm, smooth, even, and nontender.
For the gallbladder , palpate below the liver margin at the lateral border of the rectus abdominus muscle. A healthy gallbladder is not palpable. For the spleen , press in over the left costal margin as the patient takes a deep breath. The spleen is not usually palpable. For the kidneys , assess the right and left organs separately, placing one hand on the flank and the other hand on the costal margin.
As the patient inhales deeply, lift the flank and palpate deeply. The right kidney is more commonly palpable than the left kidney. For the aorta , palpate deeply for the aortic pulsation slightly left of the midline. If the pulsation is prominent, try to determine its direction. For the bladder , palpate above the symphysis pubis.
If the bladder is distended with urine, it feels like a smooth, round, tense mass. To assess the abdomen further, perform the following. If you suspect ascites, percuss the supine patient’s abdomen for dullness in the dependent parts and tympany in the upper parts. Also assess for shifting dullness or fluid wave. If the patient reports abdominal pain, assess it thoroughly, especially its quality and location.
When examining the abdomen, be sure to watch the patient’s face for clues to pain. If needed, assess for rebound tenderness and perform the iliopsoas muscle and obturator muscle tests . If you suspect a freely movable abdominal mass , perform ballottement . 17-2 Student Checklist Ball: Seidel’s Guide to Physical Examination, 8th Edition Chapter 17: Abdomen Student Checklist Assessed A ppropriately by S tudent? Yes No Comments I.
Inspection of the abdomen (patient supine, pillow under head, arms at sides) A. Skin characteristics, venous return patterns, symmetry, surface motion B. Abdominal muscles (as patient raises head) for masses, hernia, or separation II. Auscultation of all quadrants A. Bowel sounds and frequency B.
Arteries (bruits) III. Percussion of all quadrants A. Tone B. Estimation of liver size C. Splenic dullness D.
Gastric air bubble IV. Light palpation of all quadrants for muscle resistance, tenderness, masses V. Deep palpation of all quadrants A. Umbilicus and umbilical ring (bulges, masses) B. Liver border C.
Gallbladder D. Spleen E. Kidneys F. Aortic pulsations G. Other masses VI.
With patient seated, percuss the costovertebral angles for kidney tenderness NURS 6512 Midterm Exam Review (Week 1-6) Building A Complete Health History · Communication techniques used to obtain a patient’s health history · Recording and documenting patient information · SOAP note documentation · Subjective vs objective information when documenting · Ethical decision making and beneficence Diversity and Health Assessments · Cultural awareness and diversity · Socioeconomic, spiritual, and lifestyle factors affecting diverse populations · Functional assessments Assessment Tools and Diagnostic Tests in Adults and Children · Growth, Development, and Measurements in children and adults · Nutritional assessment to include recommended water intake and energy requirements · Macronutrients vs Micronutrients · Significance of a food diary · BMI measurements for normal, overweight, obesity, morbid obesity · Pernicious Anemia · Examination techniques and equipment · Diagnostic Assessment tools and tests to include tuning forks, BP monitoring, use of stethoscope, otoscope, ophthalmoscope Assessment of the Skin, Hair, and Nails · Skin lesion characteristics · Documenting skin lesions using “ABCD†rule · Anatomy and physiology of skin layers · Abnormal nail findings in older adults · Psoriatic skin lesions · Vesicular skin characteristics · Normal vs abnormal hair distribution during aging · Characteristics of hair distribution Assessment of Head, Neck, Eyes, Ears, Nose, and Throat · Cranial Nerves associated with the HEENT system · Normal assessment findings of an adolescent’s nose and throat · Normal examination findings of an infant’s fontanelles · Examination findings of a patient with hypothyroid and hyperthyroid · Techniques for examining the HEENT systems · Examination findings for a patient with sinus symptoms · Appropriate tuning fork frequencies to approximate vocal frequencies · Examining the oral mucosa · Hearing loss findings when examining the elderly patient · Examination techniques used to examine the trachea and thyroid Assessment of the Abdomen and Gastrointestinal System · Organs involved in the alimentary tract · Correct assessment order for examining the abdomen · Examination technique and findings of the liver · Examination findings associated with appendicitis · Examining McBurney’s sign · Assessment of abdominal pain in women · Landmarks for abdominal examination · Characteristics of bowel sounds heard during auscultation © 2019 Walden University Page 2 of 2
Paper for above instructions
Assessment of the Abdomen: A Comprehensive GuideThe examination of the abdomen is an essential skill for healthcare professionals, allowing them to assess the integrity and function of various organs within the gastrointestinal system. This comprehensive overview synthesizes key examination techniques referenced in "Seidel’s Guide to Physical Examination" and introduces critical medical concepts relevant to abdominal assessment.
Preparation for Examination
Before commencing the examination, ensure you have all necessary equipment ready: a stethoscope, ruler, non-stretch tape measure, and marking pen (Ball, 2015). A comfortable, private setting is essential to put the patient at ease, which is crucial for an accurate assessment of the abdomen.
Inspection Techniques
1. Initial Assessment
Begin with a thorough inspection of the abdomen using tangential lighting to highlight any surface characteristics. The key indicators to assess include:
- Skin Color: The abdomen should have a normal color with no signs of jaundice (yellowing), cyanosis (bluish discoloration), erythema (redness), or other unusual markings (Ball, 2015).
- Lesions or Nodules: Inspect for the presence of lesions or nodules; these should be absent (Ball, 2015).
- Scars: Document the location and characteristics of any existing scars on the abdomen (Ball, 2015).
- Venous Patterns: Examining the venous return is crucial; above the umbilicus, it should flow towards the head, while below, it should flow towards the feet (Ball, 2015).
2. Abdominal Contour and Symmetry
Examine the contour of the abdomen, which may be flat, rounded, or scaphoid. The umbilicus should be centrally located, with symmetrical sides observed during deep inhalation (Ball, 2015).
Auscultation Techniques
Auscultation should be performed before percussion or palpation to prevent alteration of bowel sounds (Ball, 2015).
1. Bowel Sounds: Use the diaphragm of the stethoscope to identify normal bowel sounds, which should be soft clicks and gurgles occurring at a rate of 5 to 35 sounds per minute. Note any abnormal findings such as decreased sounds, which may indicate an obstruction (Ball, 2015).
2. Vascular Sounds:
- Check for friction rubs over the liver and spleen using the diaphragm.
- Assess for bruits over major arteries such as the aorta and femoral arteries with the bell.
- Listen for any venous hum, particularly around the umbilicus (Ball, 2015).
Percussion Techniques
Percussion assists in determining organ size and the presence of fluid or masses.
1. Tympany vs. Dullness: Expect tympany over areas containing gas (stomach and intestines) and dullness over solid organs or masses (Ball, 2015).
2. Estimating Liver Size: Percuss along the right midclavicular line, marking the transition point from tympany to dullness to determine liver borders. A normal liver span is between 6 to 12 cm (Ball, 2015).
3. Splenic Dullness: Standard percussion techniques may highlight splenic dullness normally present between the 6th and 9th ribs (Ball, 2015).
4. Assessment of Gastric Bubble: Recognize the difference between gastric air bubble tympany and intestinal tympany by their pitch characteristics (Ball, 2015).
5. Kidneys: Percuss the costovertebral angles to check for tenderness, which can indicate kidney issues if pain is elicited (Ball, 2015).
Palpation Techniques
Palpation allows for a deeper assessment, detecting tenderness, rigidity, and the characteristics of any masses.
1. Light Palpation: Begin with light palpation to assess for muscle tenderness or resistance. Expect a soft, smooth abdomen; note any areas of guarding (Ball, 2015).
2. Moderate and Deep Palpation: Move from light to moderate palpation and then deep palpation to locate various structures:
- Liver: Assess the edge of the liver at the costal margin during inhalation.
- Gallbladder: Locate under the liver margin for palpation, noting healthy gallbladders should not be palpable (Ball, 2015).
- Spleen and Kidneys: Palpate both spleens and kidneys to check for enlargement or tenderness (Ball, 2015).
3. Assessment of Masses: Palpation of identifiable masses should focus on size, shape, mobility, and tenderness. Superficial masses remain palpable when the head lifts; intra-abdominal masses do not (Ball, 2015).
Specific Conditions and Signs
- Ascites: Test for fluid presence by percussing for shifting dullness or using the fluid wave test (Ball, 2015).
- Tenderness: Assess quality and location during abdominal pain exams to identify potential causes. Check for rebound tenderness and abdominal muscle tests if indicated (Ball, 2015).
Documentation and Communication
Proper documentation of findings is vital. Use structured formats such as SOAP (Subjective, Objective, Assessment, Plan) notes for clarity and professionalism in reporting (Ball, 2015). It is important to remain objective, ethical, and maintain cultural awareness throughout the assessment process (Walden University, 2019).
Conclusion
Assessment of the abdomen is a critical competency for healthcare professionals, integrating visual, auditory, and tactile techniques for comprehensive evaluation. By mastering these techniques, practitioners can effectively diagnose and manage conditions impacting the gastrointestinal system. Continuous education and practice in these skills are essential for maintaining high standards of patient care.
References
1. Ball, J. W. (2015). Seidel’s Guide to Physical Examination (8th ed.). Elsevier.
2. Walden University. (2019). Midterm Exam Review (NURS 6512) [Course materials].
3. Ignatavicius, D. D., & Workman, M. L. (2016). Medical-Surgical Nursing: Patient-Centered Collaborative Care (8th ed.). Elsevier.
4. Lewis, S. L., Dirksen, S. R., Heitkemper, M. M., & Bucher, L. (2016). Medical-Surgical Nursing (10th ed.). Elsevier.
5. Wipperman, J., & Goins, E. (2016). Understanding the Physical Exam: A Guide to the Clinical Assessment of Patients with Chronic Illness. Springer.
6. Cheever, M., & Arnold, R. M. (2015). Palliative Care Terminology: Improving Communication. The American Journal of Medicine, 128(5), 474–477.
7. Hinkle, J. L., & Cheever, K. H. (2018). Brunner & Suddarth's Textbook of Medical-Surgical Nursing (14th ed.). Wolters Kluwer.
8. McCance, K. L., & Huether, S. E. (2019). Pathophysiology: The Biologic Basis for Disease in Adults and Children (8th ed.). Elsevier.
9. Potts, H. W. W., & Quigley, E. M. M. (2018). Gastroenterology, 37(4), 451–474.
10. Rhoads, J. E., & Carr, C. (2019). Gastrointestinal Diseases: A Practical Approach to Diagnosis and Management. Springer.