N209 - Abdomen

1

RUQ?

2

LUQ?

3

RLQ?

4

LLQ?

1

epigastric?

2

Umbilical?

3

Suprapubic?

3

Hypogastric?

• liver

• gallbladder

• duodenum

• head of pancreas

• right kidney & adrenal gland

• part of ascending and transverse colon

Which organs are anatomically located in the RUQ?

• stomach

• spleen

• left lobe of liver

• body of pancreas

• left kidney and adrenal gland

• part of transverse and descending colon

Which organs are anatomically located in the LUQ?

• part of descending colon

• sigmoid colon

• L ovary and tube

• L ureter

• L spermatic cord

Which organs are anatomically located in the LLQ?

• cecum

• appendix

• R ovary and tube

• R ureter

• R spermatic cord

Which organs are anatomically located in the RLQ?

1. epigastric

2. umbilical

3. hypogastric; suprapubic

Regional names for dividing the abdomen exists, such as __________ for the area b/t the costal margins, ___________ for the area around the umbilicus, and __________ or ___________ for the area above the pubic bone.

Anorexia

What is a loss of appetite from GI disease as a result of medications, pregnancy, & mental health disorders

Pyrosis (heartburn)

= a burning sensation in esophagus & stomach from reflux of gastric acid

Visceral; internal organ

What is dull, general, poorly localized abdominal pain? What is likely the cause?

Parietal; from inflammation of peritoneum

What is sharp, precisely localized, aggravated by movement abdominal pain? What is likely the cause?

• appendicitis

• cholecystitis

• bowel obstruction

• diverticulitis

• vascular occlusion

• perforated organ

What are conditions with acute pain that require urgent diagnoses & referral?

Hematemesis

= occurs w stomach or duodenal ulcers (looks like “coffee grounds”)

Melena

= black or tarry stools from Occult blood from upper GI bleed or nontarry from iron medications

• lower GI bleed

• anal bleeding (e.g., hemorrhoids)

What does bright red blood in the stool suggest?

hepatitis

What does grey stool suggest?

peptic ulcers

_______ ______ frequently occur w use of NSAIDs, alcohol, smoking, and helicobacter pylori

• Adequate lighting

• Expose abdomen (drape genitalia & female breasts)

• Position for comfort to enhance abdominal wall relaxation

What is important when preparing to assess the abdomen?

• Empty bladder b4 examination (save specimen if needed)

• Warm stethoscope & fingers

• examine areas identified as painful last to prevent guarding

• position pt. supine w pillow below head & knees bent

What should you do to enhance abdominal wall relaxation?

Inspect, AUSCULTATE, Percuss, Palpate

Place the following in the correct order for assessment of the abdomen?

• Percuss

• Inspect

• Palpate

• Auscultate

percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds

Why shouldn’t you palpate or percuss b4 auscultating?

stand on the persons right side & look down on the abdomen, then stoop/sit to gaze across (eye level)

How would you inspect the abdomen for contour?

contour

What describes nutritional state and ranges normally from flat to rounded?

Distension

= unusual stretching & enlargement of abdomen

• implies disease

• can be symmetric or asymmetric

• Fluid (ascites, hemorrhage)

• Flatulence (gas)

• Feces (constipation)

• Fetus (pregnancy)

• Fibroid/fatal (tumor; CA)

• Fat (obesity; adipose)

What are the causes of abdominal distension?

flat; normal

1? Is the normal or abnormal?

Scaphoid; abnormal

2? Is the normal or abnormal?

rounded; normal

3? Is the normal or abnormal?

protuberated; abnormal

4? Is the normal or abnormal?

• Shine a light across the abdomen

• Have the pt. take a deep breath or perform a sit up (should stay smooth and symmetric)

• Abdomen should be symmetric bilaterally

How would you inspect the abdomen for symmetry? What should you find?

hernia

= protrusion of abdominal viscera through abnormal opening in muscle wall

Sister Mary Joseph nodule

= a hard nodule in umbilicus that occurs w metastatic CA of stomach, large intestines, ovary, or pancreas

Normally it is midline (unless previous abdominal surgery) and inverted, with no sign of discoloration, inflammation, or hernia

What should you find when inspecting the umbilicus?

= bluish periumbilical color

• occurs with intraperitoneal bleeding

What is Cullen’s sign? What does it occur with?

• smooth and even w homogenous color

• good turgor

• healed scars (not size, shape, location & character)

What are normal findings when inspecting the skin of the abdomen?

ascites

What does a tense or glistening abdomen indicate?

Striae (linae albicantes) & pigmented nevi (moles)

What are common pigment changes that may be inspected on the abdomen?

umbilical hernia

= soft, skin covered mass. protrusion of the omentum or intestine through a weakness or incomplete closer in the umbilical ring

• common in premature infants

• resolves in 1 year

diastasis recti

= midline longitudinal ridge that is a separation of the abdominal rectus muscles (occurs congenitally and as a result of pregnancy and marked obesity)

incisional hernia

= bulge near an old operative scar that may not show when a person is supine but is apparent when intra-abdominal pressure is increased

Striae

= silvery, white, linear jagged marks 1-6 cm long caused by rapid or prolonged stretching, obesity, ascites, and hormones

pink/blue

What color would you expect recent striae to be?

white/silvery

What color would you expects older striae to be?

purple/blue from diseases such as cushings

What color is abnormal striae? What could this indicate?

should not be visible

How should the venous pattern appear on the abdomen?

caput medusae

= prominent, dilated epigastric veins that occur with portal HTN, cirrhosis, ascites, or venal cava obstruction

• ABNORMAL

• thinned adipose tissue

• no

Why is the venous pattern more visible with malnutrition? Is this a normal finding?

spider veins

What venous pattern occurs with portal HTN & liver damge?

pulsations from the aorta in the epigastric area

What movement is normally seen in thin people with good muscle wall relaxation?

• abdominal aortic aneurysm

• no

What might a bounding, diffuce, and wide pulsation mean? Is this a normal finding?

• respiratory movement

• peritonitis or other abdominal problems

What movement is normal in men? What does it mean if this movement is absent?

peristalsis

Involuntary, progressive wavelike movement that is visible in very thin people.

intestinal obstruction

marked peristalsis + abdominal distension =

right; left

Peristalsis moves __________ to _________ and slightly ripples.

pyloric stenosis

With what condition (in infants), do you see reverse peristalsis?

diamond shaped

What is the male pubic hair growth factors?

upside down triangle

What is the female pubic hair growth pattern?

endocrine or hormone abnormalities, or chronic liver disease

What might alter the male and female pubic hair growth pattern?

relaxed quietly on examining table & has a benign facial expression & slow, even respirations

What demeanor would you expect from a comfortable person?

pain/discomfort

What does restlessness and constantly turning indicate?

bowel sounds are relatively high-pitched

Why should you use the diaphragm to listen to bowel sounds?

RLQ @ ileocecal valve area

Where are bowel sounds normally always present? (also where you should start listening)

• high-pitched, gurgling, clicks

• very irregular

• occur 5-30 times/min

What are normal bowel sounds?

Absent Bowel Sounds

= no sounds in any quadrant after 5 minutes (EXTREMELY UNCOMMON)

Hypoactive

= Less than 5 times/min from decreased motility

hyperactive

= loud, high-pitched, rushing, tickling sounds that are more than 30 times/min from increases motility

Borborygmi

= loud, gurgling, spashing “stomach growling” sound that is common

• type of hyperactive bowel sound

4-20%

What percentage of healthy people have a bruit heard over the abdomin?

aorta

What artery is auscultated @ #1?

renal artery

What artery is auscultated @ #2?

iliac artery

What artery is auscultated @ #3?

femoral artery

What artery is auscultated @ #4?

• no

• imaging and assessment of external tube length and pH of stomach aspirate

Can auscultation be used to place NG tubes? If not, what should be used instead?

bruit

= pulsatile blowing sound that occurs w stenosis, partial occlusion, or aneurysm

Peritoneal friction rub

= Grating, leather rubbing together, soft sound that indicates peritoneal inflammation

• Associated with each breath

• Could be from enlarged liver (lower R rib cage) or spleen (lower L rib cage) rubbing on organs or peritoneum

• Could also be from other organs, an abscess, or tumor

Venous Hum

= low pitch, soft, continuous sound

• Abnormal over liver or umbilicus (from portal hypertension, splenic artery obstructions)

• May be normal in children due to inc. blood velocity, or can be the hum of muscles

• assess relative density of abdominal contents

• locates organs

• screen for abnormal fluid or masses

What is the purpose of percussing the abdomen?

in all 4 quadrants in a clockwise manner

How should the abdomen be percussed?

tympany

What sound is predominantly heard upon percussion (bc air rises when the person is supine)?

Dullness

What sound is heard upon percussion over a distended bladder, adipose tissue, fluid or masses?

hyperressonance

What sound is heard upon percussion over gaseous distention?

• place one hand over 12th rib @ costovertebral angle on back. Thump that hand with ulnar edge of your other fist.

• assesses kidney

How should you percuss costovertebral angle tenderness? What organ is being assessed?

normally feels thud but no pain

What should a person feel when costovertebral angle tenderness is percussed?

during thoracic assessment

When is costovertebral angle tenderness assessed during the complete examination?

• to judge size, location, and consistency of certain organs

• screen for an abnormal mass or tenderness

What is the purpose of palpating the abdomen?

• Bend the person’s knees, keep palpating hand low & parallel to the abdomen

• Have the person breathe slowly

• Keep examiner’s voice low & soothing

• Use “emotive imagery” (“imagine you are dosing on the beach”)

• Determine if individual is ticklish

• Alternatively perform palpation just after auscultation

• Begin with light palpation then proceed to deep palpation

What are additional measures to enhance complete muscle relaxation?

light palpation

= gentle exploration by rolling 4 fingers and pressing in about 1 cm

voluntary

What type of guarding can occur if a person is cold, tense or ticklish?

involuntary

What type of guarding is constant board-like hardness of the muscles?

deep palpation

= exploration by rolling 4 fingers and pressing in about 5-8 cm

if the abdomen is resistant or the person is obese

When should you use the bimanual technique?

if the pt. reports pain or when tenderness is elicited during palpation

When would you assess rebound tenderness?

• Hold your hand @ 90 degrees to abdomen on a site remote from the pain/tenderness

• Push down slowly & deeply, then lift quickly

How would you assess rebound tenderness?

peritoneal inflammation

While assessing rebound tenderness, there is pain on release. What might this indicate?