The Abdomen

1.   Conduct an independent review of anatomy & physiology.

• Abdomen- large oval cavity extending from the diaphragm down to the top of the pelvis

• Linea Alba- joins flat muscles at the midline by a tendinous seam

• Rectus Abdominus- forms a strip extending the length of the midline, and the edge is often palpable

• Viscera- the internal organs in the abdominal cavity

• Solid Viscera- organs that maintain a characteristic shape, such as liver, spleen, adrenal glands, kidneys, ovaries, and uterus

  • The liver fills the right upper quadrant (RUQ), and can be palpable (along with right kidney)

  • Spleen- a soft mass of lymphatic tissue on the posterolateral wall of the abdominal cavity, right under the diaphragm

  • Pancreas- soft, lobulated gland located behind the stomach. Stretches obliquely across the posterior abdominal wall to the left upper quadrant (LUQ).

  • Kidneys- retroperitoneal (posterior to the abdominal contents), and well protected by the posterior ribs and musculature.

• Hollow Viscera- shape depends on the contents, such as the stomach, gallbladder, small intestine, colon, and bladder. Not usually palpable

  • The stomach is below the diaphragm, between the liver and spleen.

  • The gallbladder rests under the posterior surface of the liver, just lateral to the right midclavicular line

  • Small Intestine is in all the four quadrants, from the stomach’s pyloric valve to the ileocecal valve in the right lower quadrant (RLQ) where it joins the colon

2.   Landmark the anatomical location of major organs by quadrants.

• The Abdominal Wall is divided into 4 quadrants by a vertical and horizontal line bisecting at the umbilicus.

  • Midline: aorta, uterus (if enlarged), bladder (if distended)

3.   Outline relevant subjective questions.

1. Appetite:

• Any change in appetite?

• Is it increased or decreased?

• Any change in weight?

• How much weight gained or lost?

• Over what time period?

• Due to change in diet?

Anorexia: is a loss of appetite that occurs with gastro-intestinal disease, is an adverse effect of some medication, occurs with pregnancy, or occurs with psychological disorders. Loss of appetite and unexplained weight loss may be a sign of gastro-intestinal cancers such as stomach, esophageal, and pancreatic cancer.

2. Dysphagia (difficulty swallowing):

   • Any difficulty swallowing?

   • When did you first notice this?

Dysphagia occurs with disorders of the throat or esophagus (eg. later stages of esophageal cancer)

3. Food Intolerance:

   • Are there any foods you cannot eat?

   • What happens if you do eat them? Allergic reaction, heartburn, belching, bloating, indigestion

   • Do you use antacids? How often?

Examples of food intolerance are:

• lactase deficiency (resulting in bloating, excessive gas or diarrhea after ingesting milk products)

• wheat allergy or gluten intolerance (resulting in abdominal pain, distension or diarrhea)

Pyrosis (heartburn) is a burning sensation in esophagus and stomach, caused by reflux of gastric acid

Excessive belching may occur with food intolerance or hiatal hernia (stomach bugles up into the chest through the hiatal opening)

4. Abdominal Pain:

   • Do you have any abdominal pain? Please point to it.

   • O: When did the pain start?

   • L: Can you point to where it hurts?

   • D: How long have you been feeling the pain? Is the pain constant, or does it come and go?

   • C: How would you describe the character: cramping (colic type), burning in pit of stomach, dull, stabbing, aching?

   • A: Is the pain relieved by food, or is it worse after eating? What have you tried to relieve pain: rest, heating pad, change in position, medication?

   • A: What makes the pain worse: food, position, stress, medication, activity?

   • R: Is the pain in one spot (regional), or does it move around (radiate)?

   • T: Does it occur before or after meals Does it peak? When?

   • S: On a scale of 0 to 10, can you rate your pain?

   • S: Is the pain associated with menstruations or menstrual irregularities, stress, dietary indiscretion, fatigue, nausea and vomiting, gas, fever, rectal bleeding, frequent urination, vaginal or penile discharge?

Abdominal pain may be:

• visceral, from an internal organ (dull, general, poorly localized)

• parietal, from an inflammation of overlying peritoneum (sharp, precisely localized, aggravated by movement)

• referred, from a disorder from a disorder in another site

Acute pain that necessitates urgent diagnosis occurs with appendicitis, cholecystitis, bowel obstruction, or perforation of an organ.

Pain in the upper abdomen is a symptom that may occur in the later stages of gastro-intestinal neoplasms (e.g. liver or pancreatic cancer). Chronic pain of gastric ulcers usually occurs on an empty stomach; pain of duodenal ulcers occurs 2 to 3 hours after a meal and is relieved by more food.

5. Nausea/ Vomiting:

   • Any nausea or vomiting?

     • Nausea/vomiting is a common adverse effect of many medications, with gastro-intestinal disease, and in early pregnancy.

     • Nausea/ vomiting may occur in later stages of gastro-intestinal neoplasms, such as stomach, liver, or pancreatic cancer.

   • How often?

   • How much comes up?

   • What is the color?

   • Does it have an odor?

   • Is it bloody?

     • Hematemesis (blood in vomit) occurs with stomach of duodenal ulcers and esophageal varices.

   • Are the nausea and vomiting associated with colicky pain, diarrhea, fever, chills?

   • What foods did you eat in the past 24 hours? Where: at home, school, a restaurant? Has anyone else in the family had the same symptoms int he past 24 hours?

     • Consider food poisoning

   • Any recent travel? Where to? Did you drink the local water or eat fruit? Did you swim in public beaches or pools?

     • Nausea, vomiting and diarrhea occur when exposed to new local pathogens in developing countries. Water supply may be contaminated.

6. Bowel Habits:

   • How often do you have a bowel movement?

   • What is the color? Consistency?

   • Any diarrhea or constipation? How long?

   • Any recent change in bowel habits?

   • Do you use laxatives? Which ones? How often do you use them?

Assess usual bowel habits.

Stools may be black and tarry because of occult blood (melena) from gastro-intestinal bleeding, or they may be black but nontarry because of iron medications. Grey stools occur with hepatitis.

Red blood in stools occurs with gastro-intestinal bleeding or localized bleeding around the anus. A change in bowel habits, stools that are narrower than usual, blood in the stool, diarrhea, and constipation are possible symptoms of colorectal cancer and necessitate further investigations.

7. Past abdominal history:

   • . Any history of gastro-intestinal problems: ulcer, gallbladder disease, hepatitis/jaundice, appendicitis, colitis, hernia?

   • Any family history of inflammatory bowel disease (IBD), colorectal cancer, or familial adenomatous polyposis (FAP)?

     • FAP is caused by a genetic mutation that can be inherited. In individuals with FAP, the risk for colon cancer is 87% by age 45.

   • Ever had any operations in the abdomen? Please describe.

     • Abdominal adhesions (scare tissue on the abdomen) from previous abdominal surgery or infections can cause pain, nausea, vomiting, cramping, constipation, bloating, or a complete bowel obstruction.

   • Any problems after surgery?

   • Any abdominal X-ray studies? How were the results?

8. Medications:

   • What medications are you currently taking?

     • Many prescription and over-the-counter medications, such as acetaminophen and salicylates, can have toxic effects on the liver. Peptic ulcer disease occurs with frequent use of NSAIDs, alcohol, smoking, and H. pylori infection.

   • Do you take over-the counter remedies?

   • Do you take natural or herbal supplements?

     • Herbal supplements such as ginkgo biloba may cause gastro-intestinal upset, nausea and vomiting, or prolonged bleeding.

   • Do you use probiotics or prebiotics?

     • Preliminary evidence exists for several uses for probiotics, including ulcerative colitis. However, patients often rely on nonclinical information sources; therefore, nurses should offer evidence-informed advice.

9. Alcohol and Tobacco:

   • How much alcohol would you say you drink each day? Each week? When was your most recent alcoholic drink?

     • Heavy alcohol drinking is a risk factor for esophageal cancer, liver cancer, and cirrhosis of the liver. Alcohol can also increase the toxic effects of medications such as acetaminophen, resulting in damage to the liver and kidneys.

   • Do you smoke? How many packs per day? How long have you smoked?

     • Smoking is a risk factor for esophageal, stomach, and pancreatic cancers.

10. Nutritional Assessment:

    • Now I would like to ask you about your diet. Please tell me all the food you ate yesterday, starting with breakfast

      • Nutritional assessment is based on a 24-hour recall

    • Does the diet follow Eating Well with Canada’s Food Guide? Does the diet include adequate fluids and fiber?

      • Eating high-fiber foods and drinking plenty of fluids helps keep the bowels regular, helps with weight control, and may protect against colon cancer.

    • Which fresh-food markets are located in your neighborhood?

      • Many inner-city neighborhoods are fresh-food deserts, lacking produce markets but full of fast-food restaurants.

4.   Identify guidelines for preparation of objective data collection.

Preparation:

• Expose the patient’s abdomen so that it is fully visible. Drape the genitalia and female breasts.

• Enhance the abdominal wall relaxation:

  • instruct the patient to empty the bladder and save a urine specimen if needed

  • keep the room warm to avoid chilling and tensing of muscles

  • position the patient supine, with their head on a pillow, the knees bent or on a pillow, and the arms at the sides or across the chest. Discourage the patient from placing arms over the head, because this tenses abdominal musculature.

  • make sure the stethoscope endpiece in warm, hands warm, and nails short (duh)

  • inquire about painful areas, examine the area last to avoid any muscle guarding

Inspection- Inspect the Abdomen

Contour:

1. Stand on the patient’s right side and look down on the abdomen. Then stoop or sit to gaze across the abdomen.

2. Your head should be slightly higher than the abdomen.

3. Determine the profile from the rib margin to the pubic bone.

The contour describes the nutritional state and normally ranges from flat to rounded5.  

Symmetry:

1. Shine a light across the abdomen toward you or lengthwise across the patient.

2. Step to the foot of the examination table to recheck symmetry.

3. Ask the patient to take a deep breath to further highlight any change.

4. You can also ask the patient to perform a sit-up without using the hands to push up.

Even small bulges are highlighted by shadow.

Umbilicus:

Common site for piercings in young women (and men). Should not be red or crusted.

Skin:

You can check the pigment of the individual because it is often guarded from the sun

Pulsation or Movement:

Hair Distribution:

Demeanor:

Auscultation- Auscultate Bowel Sounds and Vascular Sounds

Auscultation is done next because palpation and percussion can increase peristalsis, which will give incorrect interpretation of bowel sounds.

Use the diaphragm endpiece because bowel sounds are relatively high pitched, and hold stethoscope lightly against the skin, as pushing too hard will stimulate more bowel sounds.

Start listening in the Right Lower Quadrant (RLQ), at the ileocecal valve area because bowel sounds are normally always present there.

If you hear bruit, avoid percussion and palpation.

Auscultation- Bowel Sounds:

5. Explain the use of the scratch test.

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6.   Identify the purpose for assessment for costovertebral angle tenderness.

7.   Outline developmental & cultural considerations.

8.   Identify health promotion strategies.

9.   Identify equipment needed for physical examination & safe infection prevention & control practices.

10. Outline abnormal findings: obesity, air or gas, common sites of referred pain, umbilical hernia, epigastric hernia, hypoactive and hyperactive bowel sounds, incisional hernia, abdominal friction rubs and vascular sounds, abdominal aortic aneurysm.