Abdomen + Gastrointestinal System

Health Assess Exam 2

Right Upper Quadrant

- small bowel

- liver & gallbladder

- pylorus

- duodenum

- head of pancreas

- hepatic flexure of colon

- portions of ascending & transverse colon

- right adrenal gland

- portion of right kidney

Left Upper Quadrant

- small bowel

- left lobe of liver

- spleen

- stomach

- body of pancreas

- splenic flexure of colon

- portions of transverse & descending colon

- left adrenal gland

- portion of left kidney

Right Lower Quadrant

- small bowel

- cecum & appendix

- portion of ascending colon

- lower pole of right kidney

- right ureter

Left Lower Quadrant

- small bowel

- sigmoid colon

- portion of descending colon

- lower pole of left kidney

- left ureter

- bladder

Physical Examination (IN ORDER!)

- inspection

- auscultation (must follow inspection)

- percussion

- palpation

Abdominal Assessment

- have client empty the bladder prior to assessment

- keep client warm & relaxed

- good lighting

- expose abdomen from xyphoid process to groin

- position in supine position with pillow under head and knees (if no pillow have patient bend knees)

- arms should be held across chest or be at sides

- warm hands & stethoscope

- avoid quick, unexpected movements

- watch facial expressions during exam for any pain, wincing, etc.

- have patient breathe normally

Observation and Inspection

- observe patient’s general behavior & position

- inspect abdomen for skin color w/ pink undertones, surface characteristics (scars, piercings, striae), venous patterns, contour, & surface movements

Expected Findings w/ Inspection

- abdomen is flat or round & symmetrical

- uniform in color & pigmentation

- striae (stretch marks - white/silvery purple lines that extend from umbilicus), scars, faint vascular network may be present

- no masses or nodules

- ripples of peristalsis (movement of bowels) are usually NOT visible

- non-exaggerated pulsation of the abdominal aorta may be present (typically only in thin people)

- surface characteristics should be smooth, with centrally located umbilicus

- umbilicus is depressed

- no respiratory retractions

Abdominal Distension

causes: (7 F’s)

- obesity (fat)

- air or gas (flatulence)

- ascites (interstitial fluid): buildup of fluid in the stomach

- cyst or abscess (ovarian or intra-abdominal)

- pregnancy (fetus)

- feces (constipation/fecal impaction)

- tumor (uterine fibroid, colon, or other GI cancer, benign or malignant)

- hernia (bowel pushing through abdominal wall musculature): bowels start to pop out

If abdominal distension is noted…

- MEASURE!

- place a measuring tape around the abdomen at the level of the superior iliac crests to measure the abdominal girth

Which assessment should be completed first?

Observe the color of the emesis

Before assisting Lionel to a supine position for further assessment, which action should be taken?

Encourage Lionel to empty his bladder.

To assess the symmetry of the abdomen, which action should the nurse take?

Inspect for masses or bulges.

Lionel's abdomen is symmetrical. However, you notice silvery white striae on the lower abdomen.

In response to this finding, what information should you obtain?

Past medical history of ascites & change in body mass index (BMI).

To ensure the most accurate assessment of Lionel's peristalsis, what action should the nurse take?

Complete auscultation before percussion and palpation of the abdomen.

You are auscultating the right lower quadrant (RLQ) and hear high-pitched gurgling sounds that occur irregularly. What action should you take next?

Note how frequently the sounds occur before moving to another quadrant.

You listen in all areas and hear gurgling sounds at each location, 8-10 sounds per minute total. How will you document the assessment?

Normoactive bowel sounds

After auscultating Lionel's bowel sounds, you also listen for abdominal vascular sounds, but do not hear any sounds. What action should you take in response to this finding?

Document this normal finding on the client's assessment record.

You move on to percussion. You hear a dull sound when percussing over the suprapubic area. What action should you take in response to this finding?

Observe the area for bladder distention.

While percussing the abdomen, you hear tympany over most of the abdomen, but a duller sound at the right costal margin. What follow up action should you take?

Note this location as the border of the liver.

Your goal in palpating Lionel's abdomen is to screen for any masses or tenderness. To achieve this goal, you should...

Lightly palpate the abdominal surface.

When completing the pain assessment, how will you assess for rebound tenderness?

Push down on the right side of the abdomen.

You confirm the presence of rebound tenderness and note the onset of involuntary rigidity of Lionel's abdomen. What action should you implement?

Notify the healthcare provider of the findings.

Auscultation

- auscultate abdomen for bowel sounds:

• use diaphragm of stethoscope lightly and listen in a systematic progression

• auscultate in all 4 quadrants

• start in RLQ → RUQ → LUQ → LLQ all for 15 seconds

• count every noise you hear

• always auscultate before palpation or percussion

• bowel sounds are high pitched gurgling or clicking sounds that usually occur 5 to 35 times per minute

• if no sounds are heard, then you must listen for at least 4 minutes total (one minute in each quadrant) before determining that bowel sounds are absent — EMERGENCY !

Bowel Sounds

- normoactive - irregular, high-pitched gurgles or clicks that should be noted 5-35 times per minute

- hypoactive - 1-4 sounds per minute, lower in pitch

- hyperactive - more than 35 sounds per minute, high-pitched sounds; borborygmi

Reasons for Hypoactive Bowel Sounds

- food — that cause constipation

- medications — that cause constipation

- bowel obstruction

- paralytic ileus (paralyzed bowels)

- NPO

Reasons for Hyperactive Bowel Sounds

- diarrhea

- stomach virus

- chrome’s disease

- IBD (irritable bowel disease)

Arterial Vascular Sounds

- use bell of stethoscope over aorta, renal, iliac, & femoral arteries for bruits, which occur in 4-20% of healthy people

- swishing sound

- during systole

- continuous regardless of patient position

Venous Vascular Sounds

- SHOULD NOT HEAR!

- use bell of stethoscope over the epigastric region & around umbilicus

- soft sound

- low-pitched

- continuous, louder diastolic component

- can be heard in some young, healthy individuals

- associated w/ portal hypertension & cirrhosis

Palpation

- palpate abdomen, costovertebral angle

- liver, gallbladder, spleen, & kidneys should not be felt

- can slide hands/join w/ patients to reduce tickling (have them put their hands on yours)

- observe patient for facial grimacing

expected findings:

- no tenderness

- relaxed muscles throughout

- no masses

Percussion

- performed when you suspect distension, fluid or solid masses

- percuss each quadrant (RUQ - 4 (b/c liver), LUQ - 3, LLQ - 3, RLQ - 3)

- tympany in all quadrants (most common = gas)

- dullness (suprapubic area, distension, fluid, mass)

- liver (dull, may percuss at costal margin or slightly below)

- spleen (dull, normally cannot be percussed, full stomach or stool may generate dullness in this area)

Indirect Finger Percussion Technique

- clockwise pattern

- listen for tympany & dullness

- distal aspect of middle finger of nondominant hand is against the skin; other fingers of the non-dominant hand are slightly spread apart and lifted off the skin

- strike the distal interphalangeal joint (between the cuticle & first joint) with the tip of the middle fingers of the dominant hand

- dominant hand goes through rapid flexion of the wrist which is relaxed while the forearm remains stationary

- the striking finger rebounds as soon as it makes contact

expected findings:

- feel thud, no pain

Visceral Pain

- arises from within the abdominal organ

- dull pain, poorly localized (intestinal obstruction, pancreatic tumor)

Parietal (somatic) Pain

- caused by inflammation of structure

- pain is sharp & well localized (peritonitis, ruptured appendix)

McBurney’s Point

- a point of specialized tenderness in acute appendicitis between the umbilicus & the right anterior superior iliac spine

• rebound tenderness — press firmly into the right side of the abdomen & release quickly: positive = acute appendicitis

• if present w/ involuntary rigidity of abdomen, notify the provider

Iliopsoas Muscle Test

- performed if appendicitis is suspected

- press against raised, right leg or place patient on left side & have patient hyperextend the right leg at the hip

- the iliopsoas muscle may be irritated indicating inflamed appendix

Obturator Muscle Test

- performed if ruptured appendix or pelvic abscess is suspected

- raise the patient’s right leg w/ the knee flexed

- rotate the leg internally at the hip

- pain in hypogastric region indicates irritation to obturator muscle

Incontinence

- loss of bladder control (NEED TO KNOW TYPES!)

• stress: most common — involves loss of small amounts of urine when there is pressure on the bladder (ex. laughing, sneezing, coughing, pregnancy, jumping)

• urge: sudden strong need to void (urinate/pee) that usually leads to urine leakage due to weak urethral muscles (caused by Parkinson’s, multiple sclerosis, diabetes)

• overflow: urine leaks from a bladder that is always full; experience dribbling/leakage; can’t empty bladder fully (caused by enlarged prostates)

• functional: can’t get to the bathroom due to mobility issues (arthritis, cognitive issues like dementia, etc.)

Problems w/ Urination

- bladder infection: pain or burning w/ urination

- urinating frequent, small amounts: infection, incontience, enlarged prostate

- fever, chills, backpain: kidney infection (pyelonephritis) or kidney stone

- dark urine: kidney or liver disease (more so jaundice than dark urine)

- edema, low urine output: kidney failure causing fluid retention (shortness of breath, sudden weight gain — could be indicative of kidney disease)

Pediatric Considerations

- inspection: (newborn) synchronous abdominal & chest wall movements; diastasis rectus may be noted during crying, visible pulsations (epigastric region) are common, presence of umbilical cord

- palpation: (newborn) edge of liver may be palpable (1-2 cm below right costal margin); spleen is not palpable (maybe just the tip); both kidneys may be noted w/ deep palpation

- inspection: (toddlers/children) round (pot) belly; school children may have this rounded appearance until age 13; umbilical hernia can be present (most resolve spontaneously). Belly breathers until age 7

- palpation: (toddlers/children) ticklish

A nurse is performing a routine check-up on an adult male. As the nurse begins the abdominal assessment, the nurse knows to:

Begin with observation of the patient’s general behavior.

When percussing the kidneys for tenderness, the nurse should:

Use the direct or indirect method of percussion.