Abdomen

The abdomen is considered from the

Diaphragm to brim of pelvis

The abdomen is divided into

4 quadrants

How to imagine left, right upper/low quadrants

Look down at yourself. It is your left or right on self.

Other person their left will be your right.

Location of aorta

Left of midline in upper abdomen

Upper abdomen name

Epigastric

Middle abdomen name

Umbilical

Lower abdomen name

Hypogastric or suprapubic

Peritoneum lies

Between muscles and organs

Small intestines location

All 4 quadrants

LUQ contains which organs

Stomach

Spleen

Left lobe of liver

Body of pancreas

Left kidney and adrenal gland

Splenic flexure and colon

Part of transverse and descending colon

RUQ contains which organs?

Liver

Gallbladder

Duodenum

Head of pancreas

Right kidney and adrenal gland

Hepatic flexure of colon

Part of ascending and transverse colon

RLQ contains which organs?

Appendix

Cecum

Right ureter

LLQ contains which organs?

Part of descending colon

Sigmoid colon

Left ureter

Midline contains

Bladder

Can you palpate the spleen?

No

Can you palpate the pancreas?

No

Can you palpate the kidneys? Why?

No bc its protected by the ribs and musculature

Which kidney is lower? And why?

Right kidney 1-2cm bc of liver placement

What is the costovertebral angle?

Angle formed by the 12th rib and verterbral column on the posterior thorax overlying the kidneys

Infants and children structure abdomen

Liver takes up more space

Urinary bladder higher

Easier to palpate organs b/c less muscles

Aging adult structure of abdomen

Fat accumulates in suprapubic area in females

Males also show some fat

Musculature relaxes in both genders

Why does fat accumulate in the suprapubic region of the female aging adult?

Decreased estrogen levels

How is adipose tissue redistributed in aging adults?

From face and extremities to abdomen and hips

Salvation in aging adult

Decreases=dry mouth and decrease taste

Esophagus and aging adult

Emptying is delayed=increases risk for aspiration

Aging adult fed in supine position?

Increases risk for aspiration

Gastric acid secretion decreases with age causing

Pernicious anemia, iron deficiency anemia, malabsorption of calcium

Pernicious anemia

Vitamin B12 deficiency

Gallstones in the aging adult:

Increases with age especially females

Think FFF (fat , 40s, fertile)

liver and aging adult

Size and metabolism decrease, especially after 80

If drug metabolism by liver is impaired what are nursing implications?

Elevated drug serum levels

Be careful with dosing question provider

Bowel and aging adult

Constipation

common causes of constipation

Decreased physical activity

Inadequate intake of water

Low-fiber diet

Side effects of medications

Irritable bowel syndrome

Bowel obstruction

Hypothyroidism

Inadequate toilet facilities

Overall aging adult is most likely (general concepts)

Under nutrition or over nutrition

Poor health, isolation, alcoholism, limited functional, poverty, polypharmacy

Decline in family support

Reasons that interfere with aging adult nutrition

Facilites for meal prep, transportation to grocery store, physical limitations, income, and social isolation

Physiological changes in aging adult that directly affect nutritional status

Poor teeth

Poor vision

Poor smell and taste

Decreased saliva production & gi absorption

Slowed GI motility

Subjective data abdomen

Appetite

Dysphagia or odynophagia

Dyspepsia (heart burn)

Food intolerance

Abdominal pain

Nausea and vomiting

Bowel habits

Past abdominal history

Medications

Alc, drug and cigs

Nutritional assessment (24 hour recall)

Abdominal history disease processes

Ulcer

Gallbladder disease

Hepatitis/jaundice

Appendicitis

Colitis

Hernia

Surgeries

X-ray

Any painful areas? When do you exam those

Exam painful areas last to avoid muscle guarding

Use distraction during assessment by

Breathing exercises, emotive imagery, low soothing voice, person relating abdominal history while palpating

Which measures before assessment will enhance the abdominal wall relaxation?

Empty bladder

Warm room

Supine, head on pillow, knees bent or on pillow, and arms at side or across chest

Stethoscope warm, hands warm, short fingernails

Discourage the pt from placing their hands where? Why?

Over head b/c it tenses abdominal muscles

inspect what on abdomen

Contour, symmetry, umbilicus, skin, pulsation/movement and demeanor

How to inspect contour

Stand on right side and look down

Then stoop to gaze across abdomen

scaphoid abdomen contour and caused by

abdomen caves in. Caused by malnourishment

Normal findings from contour

Flat or rounded

proturberant abdomen countour. Causes?

Abdomen sticks out farther than usual caused by excess fat, obesity, buildup of substances

how to inspect symmetry of the abdomen?

Shine a light across abdomen toward you or lengthwise across person

Abnormal findings of symmetry abdomen

Bulges, masses, hernia, asymmetrical

What is a hernia?

protrusion of abdominal viscera through abnormal opening in muscle wall

If any abnormal findings on symmetry of abdomen what should you do?

Recheck by stepping to foot of examination table

Ask person to take deep breath

Umbilicus of abdomen inspection normal findings

Normally midline and inverted, no discoloration, inflammation, or hernia

Abnormal findings of umbilicus

Everted w ascites or underlying mass

Deeply sunken w/ obesity

Enlarged and everted w umbilical hernia

Inspection of skin abdomen normal findings

Surface smooth and even w/ homogenous color

Skin findings on abdomen that may be normal

Striae (stretch marks)

Pigmented nevi (moles)

What reflects healthy nutrition on abdomen skin

Good skin turgor

If a scar is present on abdomen,

Draw in person's records, indicate length and cm

Ascites

abnormal accumulation of fluid in the abdomen

Skin will be glistening and taut

spider angioma

Red center with radiating red legs (enlarged small vessels)

spider angioma is a finding on the abdomen for which disease processes

Portal hypertension and liver disease

How to inspect pulsation or movement of abdomen

Use penlight, shine across

Normal findings inspection pulsation or movement abdomen

Pulsation from aorta in epigastric area mostly thin people

Respiratory movement seen, mostly in males

Abnormal findings pulsation/movement inspection of abdomen

Aorta w/ widened pulse pressure=hypertension, aortic insufficiency, thyrotoxicosis

Visible peristalsis w/ distention=intestinal obstruction

order of abdomen assessment

Inspect, Auscultate, Percuss, Palpate

When auscultating the abdomen use which part of stethoscope

Diaphragm (high pitch sounds)

auscultation order of abdomen

RLQ, RUQ, LUQ, LLQ

(RLQ is first bc ileocecal valve w/ bowel sounds always present here)

normal bowel sounds

high-pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5 to 30 times per minute.

(They occur irregularly so don't count)

hyperactive bowel sounds

loud, high-pitched, rushing, tinkling sounds that signal increased motility

Hypoactive or absent bowel sounds

diminished or absent, slower motility

Hyperactive sounds disease processes

Early mechanical obstruction, gastroenteritis, brisk diarrhea, laxative use, subsiding paralytic ileus

Causes of Hypoactive or absent bowel sounds

Abdominal surgery

Inflammation of peritoneum

Late bowel obstruction

Fairly common hyperactive bowel sound when you feel your stomach "growling"

borborygmus

Perfectly "silent abdomen" is uncommon so

you must listen for 5 minutes by your watch before deciding bowel sounds are completely absent

Auscultation of vascular sounds abdomen

Note presence of vascular sounds or bruit

Normal findings of vascular sounds in abdomen

Usually no such sound

What is a systolic bruit?

pulsatile blowing sound and occurs with stenosis, occlusion or aneurysm of artery

venous hum (innocent murmur) and peritoneal friction (peritonitis) rub vascular sounds of abdomen

are rare

tympany in abdomen

loud high pitched musical or "drum like" over air/gas

tympany, the normal sound percussed over the abdomen, is caused by what

hollow (air filled) organs

When percussion the abdomen you are percussing for general

Tympany

How to percussion for general Tympany?

Lightly percuss all 4 quadrants

Tympany usually predominates bc air in intestines rises to surface when supine

Abnormal findings of abdomen while percussing

Dullness=distended bladder, fat, fluid, or mass

Hyper-resonance=gaseous distention

costovertebral angle tenderness

Indirect first percussion causes tissues to vibrate instead of producing a sound

How to assess kidneys with percussion?

Place hand over 12th rib at CVA on back

Thump that hand with ulnar edge of your other first

Normally feels thud but no pain

When palpating ticklish patients

Have them Move their hands on top of yours around as you palpate; ppl aren't ticklish to themselves

Or pretend to auscultate and curl fingers around stethoscope then slide it out as pt becomes use to it

Voluntary guarding vs involuntary rigidity

V: pt cold, tense, ticklish, bilateral, muscles relax slightly during exhalation

IV: constant hardness of muscles, protective mechanism from acute inflammation of peritoneum. Area usually painful as they try to sit up. May be unilateral

How to light palpate the abdomen

First 4 fingers together depress skin 1 cm

Rotary motion

Do not drag, lift fingers to next location

Do not search for organs

How to deep palpate abdomen

5-8 cm (3-4in)

Same technique as light

How do you overcome the resistance of a large abdomen?

Use bimanual technique

How to perform bimanual technique?

Two hands on top of each other

Top hand pushes, bottom hand relaxes to concentrate on palpation

Normally deep palpable abdominal structures

Right Lower pole of kidney

Normal liver edge

Xiphoid process

Pulsatile aorta

Rectum muscles, lateral borders

Cecum/ascending colon

Uterus

Full bladder

Sacral promontory

Sigmoid colon

Normal tenderness is noted when palpating the

Sigmoid colon LLQ bc poop is being formed there

How to palpate liver

Left hand under back parallel to 11th and 12th ribs and lift up

Right hand on RUQ, fingers parallel to midline

Push deeply down under right costal margin

Ask pt to take deep breath (normal to feel edge of liver during inhalation should feel like a firm regular ridge)

Hooking technique-Murphy's sign

Alternative method of palpating liver

Stand up at pt shoulders and face feet

Hook fingers over costal margin from above

Ask pt to take deep breath (try to feel liver edge)

Enlarged liver is called

hepatomegaly

palpating the spleen: describe the technique

Reach left hand over abdomen and behind left side at 11th and 12th rib, lift up

Right hand obliquely on LUQ w/ fingers pointing toward left axilla just inferior to rib margin

Push deeply down and under left costal margin

Ask person to breath (should feel nothing)

How large is a palpable spleen

3 times normal size

If you palpate a spleen do what?

Do not palate bc it is friable and can rupture easily

Enlarged spleen

splenomegaly

Why would the spleen be enlarged?

Mononucleosis, leukemia, trauma, HIV (This organ plays a role in immune system)