Assessment of the Abdomen and Gastrointestinal System

Peritoneum

Protective abdominal lining

Parietal Layer

Lines abdominal wall

Visceral Layer

Covers organs

Peritoneal Cavity

Space between parietal and visceral layers; serous fluid

Alimentary Tract

Mouth-> Esophagus-> Stomach-> Small intestine-> Large intestine-> Rectum-> Anus

Liver

-Bile production/secretion
-Clotting factor production
Detoxification

Gallbladder

Stores and releases bile into small intestine

Pancreas

Releases insulin, glucagon, and pancreatic enzymes

Spleen

Removes old, damaged, and malformed RBCs and platelets from circulation
-Activates B and T lymphocytes

Urinary tract

-Kidneys
-Ureters
-Bladder
-Urethra

Common iliac arteries

Level of umbilicus

Right and left renal arteries

Perfuse kidneys

What is a question you should ask your patient when it comes to bowel movements?

When was your last bowel movement?

Anorexia

Lost of appetite

Dysphagia

Difficulty swallowing
-GI

Dysphasia

Difficulty with speech

Melena

-Black, tarry stools
-Indicates upper GI bleed

Steatorrhea

Fat in stool
-pancreatitis

Incontinence

Lack of voluntary control over urination or defecation

Frequency

Often but small amounts

Urgency

Cannot wait to go

Oliguria

Low urine output

Anuria

No urinary output

Hematuria

Blood in urine

What are the five points that divide the 4 quadrants?

-Superior: Costal margin
-Inferior: Pubic symphysis
-Lateral: Right and left iliac crests
-Central: Umbilicus

Organs in Right Upper Quadrant (RUQ)

-Liver
-Gallbladder
-Head of Pancreas
-Right adrenal gland
-Right kidney

Organs in Left Upper Quadrant (LUQ)

-Spleen
-Stomach
-Body of Pancreas
-Left adrenal gland
-Left kidney

Organs in Right Lower Quadrant (RLQ)

-Small intestine
-Cecum
-Appendix
-Ascending colon
-Right kidney
-Right ureter
-Right ovary and fallopian tube
-Right spermatic cord

Organs in Left Lower Quadrant (LLQ)

-Left kidney
-Sigmoid colon
-Descending colon
-Left ureter
-Left ovary and fallopian tube
-Left spermatic cord

Lighting for Assessment

Strong overhead, tangential lighting

Positioning for Assessment

Supine, head on pillow, knees bent/flat, arms at side, empty bladder

Where to view for assessment

-Above the head
-From the side: at EYE LEVEL

Contours of the abdomen

1. Flat
2. Scaphoid- sunken/concave
3. Rounded
4. Protuberant-ascites

Are striae a normal variation?

Yes

What should you think when the abdomen is bruised?

-Internal hemorrhage
-Abuse

Inverted umbilicus

Sunken (innies)

Everted umbilicus

-Ascites
-Mass
-Pregnancy

Enlarged umbilicus

Umbilical hernia: not dangerous, go away on it's own

Cullen's Sign

-INTERNAL HEMMORHAGE
-Edema and bluish/purple discoloration

Cullen's Sign could be due to

-Ectopic pregnancy
-Hemorrhagic pancreatitis
-Leaking aortic aneurysm (AAA)
-Splenic rupture

What is the order for assessing the abdomen?

1. Inspection
2. Auscultation
3. Percussion
4. Palpation

Why do you auscultate before percussion and palpation?

So the presence or absence of bowel sounds or pain is not altered

Hyperactive (borborygmi) bowel sounds

-"stomach growling"
-Diarrhea

Hypoactive bowel sounds

-Paralytic ileus
-Bowel obstruction

Absent bowel sounds

No sounds x 5 minutes

What part of the bell do you use to auscultate for vascular sounds?

Bell

What should be heard when auscultating vascular sounds?

No sounds

Tympany

-Presence of gas
-Stomach, intestines
-Most common percussion sound heard

Dullness

-Organ
-Fluid
-Mass

Percuss Liver Span

-Right MCL
1. Below level of umbilicus, percuss up until TYMPANY to DULLNESS
2. Over lung, percuss down until RESONANCE to DULLNESS
-N: 6-12cm

Direct Percussion

Each costovertebral angle with ulnar surface of fist

Indirect Percussion

Place hand over CVA and tap hand with ulnar surface of fist

+CVA Tenderness

-Kidney infection -Kidney stone
-Nephrolithiasis

Light Palpation

-BSN level
-Palmar surface of hands/finger pads
-0-1cm
-Assess painful areas last

Deep Palpation

-Advanced practice
-2-4cm

Voluntary Guarding

Voluntary contraction of the abdominal muscles to avoid pain

Involuntary Guarding

Reflex contraction or spasm of the abdominal muscles on palpation
-caused by peritoneal inflammation

Visceral Pain

-Vital organ pain
-Vague
-Achy, crampy, deep pain
-Better with applied pressure
-Ex. Menstrual cramps, colon discoloration

Parietal Pain

-Pinpoint
-Sharp, stabbing, severe
-Worse with applied pressure
-Ex. bowel perforation/ appendix rupture

Referred pain

Felt in an area that is distant from the source

Fluid Wave Test

-Test for Ascites
-Positive test=fluid wave present

Iliopsoas (Psoas) Sign

-Test for appendicitis
-Supine: Lift R leg straight
-L-lying: Extend R leg backwards
-Irritation of Psoas M group by inflamed appendix-> pain
-Positive test=Increased RLQ pain

Obturator Sign

-Test for appendicitis or pelvic abscess
-Flex knee, internally rotate R hip
-Stretching of M-> increased irritation of appendix
-Positive test= increased RLQ pain

McBurney's point

-Point of maximal tenderness in acute appendicitis

Rebound Tenderness

-Sign of peritonitis
-Apply pressure to abdomen, then quickly release
-Increased pain UPON RELEASE=Rebound tenderness

Murphy's Sign

-Indicates gallbladder inflammation
-Push fingers under costal margin and instruct pt. to take a deep breath
-Pain=Positive Murphy's sign

Do infants have and increased or decreased musculature?

Decreased

Pregnancy Considerations

-Decreased GI motility
-Constipation
-Hemorrhoids
-Skin changes

Elderly Considerations

-Decreased saliva production
-Increased fat deposits
-Decreased musculature
-Decreased muscle and sphincter tone
-Decreased active bacterial flora

GERD

-Chronic reflux of gastric acid into esophagus
-Symptoms: heartburn, dysphagia, chest pain, cough, sour taste
-Worse with lying down
-Relieve with antacids, sitting up

Hernias

-Protrusions of tissue/organ through an abdominal opening

Hiatal Hernia

Stomach protrusion through diaphragm

Incisional hernia

-Site of previous surgery
-Early repair is important

Crohn's disease

-Chronic inflammation of the intestinal tract
-Cobble stone appearance

Ulcerative colitis

-Ulcers in colon
-Why a colostomy is needed

Diverticulitis

-Inflammation of the diverticula(pockets/herniations in muscular wall of colon)
-LLQ pain
-Avoid nuts and seeds
-Pain improvement after bowl movement

Bladder Cancer

-Smoking is #1 risk
-More in MEN
-More in WHITES

Colorectal Cancer

-Most diagnosed through ASYMPTOMATIC patients
-Screening at 45 years old

Advanced Signs of Colorectal Cancer

-Blood in stool
-Weight loss, fatigue
-Stool pattern change
-Abdominal pain, bloating

Hepatitis

Viral infection of the liver
-Most common: A, B, And C

Cirrhosis

Diffuse destruction of liver cells; replaced by fibrous scar tissue
-End-stage

Symptoms of Liver Disease

-Enlarged liver
-Jaundice
-Tan/pale stools
-Ascites
-Dark urine

Urinary Tract Infections

-DYSURIA: painful
-Frequency
-Urgency
-Suprapubic pain
-Cloudy and/or malodorous urine
-Hematuria (blood)
-Pyelonephritis
-Older adults may present w/confusion

Honey/amber Urine

Dehydrated

Brown Urine

-Severely dehydrated
-Liver disease

Pink/red Urine

-Eaten beats/blueberries/rhubarb
-Blood in urine

Blue/Green Urine

-Rare genetic disease
-Bacterial medication
-Food dye

Considerations for Infants: Nutrition Assessment

-Breastfeeding/bottle
-Food introduction

Considerations for Toddlers: Nutrition Assessment

Irregular eating patterns

Considerations for Adolescents: Nutrition Assessment

-Increased caloric needs
-Boys: 2,800
-Girls: 2,200

Considerations for Pregnancy: Nutrition Assessment

-N/V secondary to hormonal changes
-Constipation secondary to decreased motility
-Higher caloric need

Considerations for Older Adults: Nutrition Assessment

-Appetite decrease
-Change in taste and smell
-Decreased salivation
-Difficulty swallowing and chewing
-Impaired ability to acquire and prepare food

Normal BMI

18.5-24.9

Age-Related Variations: Infants

-Utilize growth charts
-Plot height and weight vs. age

Waist-to-Hip Ratio

Women: 0.8 or less
Men: 1 or less

Anorexia Nervosa

-Refusing to eat
-Extreme thinness
-Other symptoms of protein-calorie malnutrition

Bulimia Nervosa

-Recurrent binge-and-purge eating cycles
-Chronic irritation or erosion of the pharynx, esophagus, and teeth

Binge-eating Disorder

-Consumption of large quantities of food until uncomfortably full
-Often feels out of control during the binge episodes

Nutrition: Physical Exam

-Hair, skin, and nails
-Eyes
-Oral cavity
-Muscle strength and coordination