Untitled Flashcards Set

hronic Arterial Insufficiency Chronic Venous Insufficiency

Arterial (Ischemic) Ulcer Venous (Stasis) Ulcer

Buildup of fatty plaques on intima (atherosclerosis) plus hardening, calcification of arterial wall (arteriosclerosis).S:Deep muscle pain in calf or foot, claudication (pain with walking); pain worsens with leg elevation; pain at rest indicates worsening of condition.

O:Coolness in only one foot or leg, pallor, elevational pallor, and dependent rubor; diminished pulses; systolic bruits; signs of malnutrition (thin, shiny skin; thick-ridged nails; atrophy of muscles); distal gangrene.Ulcers occur at toes, metatarsal heads, heels, and lateral ankle and are characterized by pale ischemic base, poor granulation, well-defined edges, and no bleeding; they look dry and punched out; may have eschar, indicating necrosis. Arterial ulcers are more common in those with smoking, diabetes, hyperlipidemia, and hypertension.

After acute DVT or chronic incompetent valves in deep veins. Venous ulcers account for 80% of lower leg ulcers.S:Aching pain in calf or lower leg, worse at end of day, worse with prolonged standing or sitting; pain lessens with leg elevation. Itching with stasis dermatitis.

O:Lower leg edema that does not resolve with diuretic therapy. Firm, brawny edema; coarse, thickened skin; pulses normal; brown pigment discoloration; petechiae; dermatitis. Venous stasis causes increased venous pressure, which then causes red blood cells (RBCs) to leak out of veins and into skin. RBCs break down to hemosiderin (iron deposits), which are brown pigment deposits. May have varicose veins.15 Borders are irregular. Venous ulcers are shallow and may contain granulation tissue. A weepy, pruritic stasis dermatitis may be present.Ulcers occur at medial malleolus and tibia; characterized by bleeding, uneven edges.

Neuropathic Ulcer

Diabetes hastens changes described with arterial ischemic ulcer, with generalized dysfunction in all arterial areas: peripheral, coronary, cerebral, retinal, and renal. Peripheral diabetic ulcer has its pathogenesis in sensory neuropathy with loss of protective sensation, autonomic neuropathy with decreased sweating and dry skin, and motor neuropathy with foot deformity.9 Ulcers then occur with repetitive stress over these at-risk areas. Diabetic ulcers may become infected, heal poorly, or become chronic. About 75% of lower-extremity amputations occur with diabetes; these amputations have high mortality rates (5-year survival is 29%).16 Symptoms include numbness and tingling, pain, weakness, loss of balance, falling, allodynia. Signs include decreased reflexes, loss of proprioception, loss of vibration sensation, small muscle wasting, loss of warm and cold sensation and pinprick, decreased reflexes, poor blood flow, and cold feet. Without careful vigilance of pressure points on feet, ulcer may go unnoticed.

S, Subjective data; O, objective data.

See Illustration Credits for source information.

TABLE 21.5

Peripheral Vascular Disease in the Legs

Chronic Venous Disease Acute Venous Disease

Superficial Varicose Veins Deep Vein Thrombophlebitis

Normal leg veins have dilated as a result of chronic increased venous pressure (obesity, multiple pregnancies, prolonged standing) and incompetent valves that permit reflux of blood back toward leg instead of forward toward heart. Varicose veins are 3 times more common in women than men. Older age increases risk as a result of thinning of elastic lamina of veins and degeneration of vascular smooth muscle. Size ranges from 1 mm to 1 cm in diameter; color ranges from red to blue or purple.

S:Aching, heaviness in calf, easy fatigability, restless legs, burning, throbbing, cramping. Localized itching, tingling, burning, or pain in these veins.21

O:Dilated, tortuous veins. New varicosities sit on surface of muscle or bone; older ones are deep and feel spongy. May see generalized leg swelling.21

A deep vein is occluded by a thrombus, causing inflammation, blocked venous return, cyanosis, and edema. Virchow triad is the classic 3 factors that promote thrombogenesis: stasis, hypercoagulability, and endothelial dysfunction.20 Cause may be prolonged bed rest, history of varicose veins, trauma, infection, cancer, obesity, immobility, heart failure, or the use of estrogen hormones. Requires emergency referral because of risk for pulmonary embolism. Note that upper-extremity DVT is increasingly common as a result of frequent use of invasive lines such as central venous catheters.

S:Sudden onset of intense, sharp, deep muscle pain.

O:Increased warmth; swelling (to compare swelling, observe usual shoe size as in above photo); redness; dependent cyanosis is mild or may be absent; tender to palpation; apply Wells criteria as on p. 522.

See Illustration Credits for source information.

TABLE 21.6

Peripheral Artery Disease

A diagram illustrates occlusion. A V-shaped structure of a food pipe is marked as the carotid artery bifurcation. Starting from the top left to the bottom small branch-shaped structure arises below the neck marked as the vertebral artery junction. A junction of vessels present below the abdomen area is marked as an aortoiliac junction. The left side and right inverted u-shaped vessels are marked as the common iliac artery and the internal iliac artery. All three commonly marked as the obstruction produces intermittent claudication, decreased femoral pulses, and impotence in males. The elongated vessels besides the growing region are marked as the femoral bifurcation and femoral artery. An elongated vessel near the knee region is marked as the popliteal artery. This artery divides into 2 sub arteries marked as the posterior tibial artery and anterior tibial artery. Starting from the right top to the bottom, the V-shaped vessels present below the ear marked as the carotid artery bifurcation. An arch is present above the heart and is marked as an aortic arch. A junction is present below the heart and is marked as the superior mesenteric artery junction. A horizontal vessel is present below this is marked as the renal artery junction. The vessel present below the abdominal reason marked as the abdominal aorta.

Occlusions

Occlusions in arteries are caused by atherosclerosis, which is the chronic gradual buildup of (in order) fatty streaks, fibroid plaque, calcification of the vessel wall, and thrombus formation. This reduces blood flow with vital oxygen and nutrients. Risk factors for atherosclerosis include obesity, cigarette smoking, hypertension, diabetes mellitus, elevated serum cholesterol, sedentary lifestyle, and family history of hyperlipidemia.

Aneurysms

An aneurysm is a sac formed by dilation in the artery wall. Atherosclerosis weakens the middle layer (media) of the vessel wall. This stretches the inner and outer layers (intima and adventitia), and the effect of blood pressure creates the balloon enlargement. The most common site is the aorta, and the most common cause is atherosclerosis. The incidence increases rapidly in men older than 55 years and women older than 70 years; the overall occurrence is 4 to 5 times more frequent in men.

Right Upper Quadrant (RUQ) Left Upper Quadrant (LUQ)

Liver

Gallbladder

Duodenum

Head of pancreas

Right kidney and adrenal

Hepatic flexure of colon

Part of ascending and transverse colon

Stomach

Spleen

Left lobe of liver

Body of pancreas

Left kidney and adrenal

Splenic flexure of colon

Part of transverse and descending colon

Right Lower Quadrant (RLQ) Left Lower Quadrant (LLQ)

Cecum

Appendix

Right ovary and tube

Right ureter

Right spermatic cord

Part of descending colon

Sigmoid colon

Left ovary and tube

Left ureter

Left spermatic cord

Midline

Aorta

Uterus (if enlarged)

Bladder (if distended)

he Aging Adult

Aging alters the appearance of the abdominal wall. After middle age, some fat accumulates in the suprapubic area in females as a result of decreased estrogen levels. Males also show some fat deposits in the abdominal area, which accentuates with a more sedentary lifestyle. With further aging, adipose tissue is redistributed away from the face and extremities and to the abdomen and hips. The abdominal musculature relaxes.

Age-related changes occur in the GI system but do not significantly affect function as long as no disease is present.

• Salivation decreases, causing a dry mouth and a decreased sense of taste (discussed in Chapter 17).

• Esophageal emptying is delayed. If an aging person is fed in the supine position, it increases risk for aspiration.

• Gastric acid secretion decreases with aging. This may cause pernicious anemia (because high gastric pH decreases vitamin B12 absorption), iron-deficiency anemia, and malabsorption of calcium.

• The incidence of gallstones increases with age, occurring in 10% to 20% of middle-age and older adults, being more common in females.

• Liver size decreases by 25% between the ages of 20 and 70 years, although most liver function remains normal. Drug metabolism by the liver is impaired, in part because blood flow through the liver and liver size are decreased. Therefore the liver metabolism that is responsible for the enzymatic oxidation, reduction, and hydrolysis of drugs is substantially decreased with age. Prolonged liver metabolism causes increased side effects (e.g., older people taking benzodiazepines have an increased risk of falling and thus of hip fracture).

• Aging people frequently report constipation. Chronic constipation occurs more frequently in the aging than in the general population, and aging women are affected 2 to 3 times more than their male counterparts. A higher incidence of constipation in the aging results in greater use of laxatives, with a majority of aging patients using laxatives daily. Because many adults are confused as to what defines constipation, the Rome III standardizes symptom criteria for functional constipation. These symptoms include reduced stool frequency (less than 3 bowel movements per week) and other common and troubling associated symptoms (i.e., straining, lumpy or hard stool, feeling of incomplete evacuation, feeling of anorectal blockage, use of manual maneuvers).

Constipation is not a physiologic consequence of aging. Common causes of constipation include decreased physical activity, inadequate intake of water, a low-fiber diet, side effects of medications (opioids, tricyclic antidepressants), irritable bowel syndrome, bowel obstruction, hypothyroidism, and inadequate toilet facilities (i.e., difficulty ambulating to the toilet may cause the person to deliberately retain the stool until it becomes hard and difficult to pass).

xaminer Asks Rationale

1. Appetite

• Any change in appetite? Is it a loss of appetite?

• Any change in weight? How much weight gained or lost? Over what time period? Is the weight loss caused by diet?

Anorexia is a loss of appetite from GI disease as a side effect to some medications, with pregnancy, or with mental health disorders.

2. Dysphagia

• Any difficulty in swallowing? When did you first notice it? Is there any associated pain? Any coughing or choking when swallowing? Any worse with liquids versus solids?

Dysphagia occurs with disorders of the throat or esophagus, such as thrush (candida infection), neurologic changes (e.g., stroke), or obstruction (e.g., solid mass or tumor).

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?

Food intolerance (e.g., lactase deficiency resulting in bloating or excessive gas after taking milk products).

Pyrosis (heartburn), a burning sensation in esophagus and stomach from reflux of gastric acid.

Eructation (belching).

4. Abdominal pain

• Any abdominal pain?

• P: How did it start? What makes it worse: position, stress, medication, activity? Is pain relieved by food or worse after eating? What have you tried to relieve pain: rest, heating pad, change in position, medication, dietary modifications?

Abdominal pain may be visceral from an internal organ (dull, general, poorly localized); parietal (somatic) from inflammation of overlying peritoneum (sharp, precisely localized, aggravated by movement); or

• Q: Please describe the quality: cramping (colic type), burning in pit of stomach, dull, stabbing, aching?

• R: Please point to region of abdominal pain. Is the pain in one spot, or does it move around or radiate?

• S: How severe is the pain? (See Chapter 11, p. 171, for pain scales). Is it associated with menstrual period, stress, certain foods, fatigue, nausea and vomiting, gas, fever, rectal bleeding, frequent urination, vaginal or penile discharge?

• T: Tell me about the timing. How long have you had it? Constant, or come and go? Occur before or after meals? Does it peak? When?

• U: Has this pain affected your life and daily activitie22?

referred from a disorder in another site (see Table 22.3, p. 566). Acute pain requiring urgent diagnosis and referral occurs with appendicitis, cholecystitis, bowel obstruction, diverticulitis, vascular occlusion, or a perforated organ.Chronic pain of gastric ulcers occurs usually 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? How often? How much comes up? What is the color? Is there an odor?

Nausea/vomiting is common with GI disease, many medications, pregnancy.

• Is it bloody or does it have a brown-flecked “coffee ground” appearance?

Hematemesis occurs with stomach or duodenal ulcers and esophageal varices. Looks like “coffee grounds” due to exposure to gastric acid.

• Is the nausea or vomiting associated with colicky pain, diarrhea, fever, chills?

• What foods did you eat in the past 24 hours? Where? At home, school, restaurant? Is there anyone else in the family with same symptoms in past 24 hours?

Consider food poisoning or other types of bacterial or viral gastroenteritis.

• Any recent travel? Where to? Drink the local water or eat fruit? Swimming in public beaches or pools?

Nausea, vomiting, and diarrhea can 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? How frequent are stools? Any other symptoms occur with diarrhea?

• Any recent change in bowel habits?

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

Assess usual bowel habits.

Black stools may be tarry due to occult blood (melena) from upper GI bleeding or nontarry from iron medications. Bright red blood occurs with lower GI bleeding or localized anal bleeding (e.g., hemorrhoids). Gray stools occur with hepatitis.Diarrhea has many causes: acute vs. chronic, infectious vs. noninfectious. Especially concerning signs are fever and signs of dehydration (which can lead to hypovolemic shock).13

7. Past abdominal history

• Any history of GI problems: ulcer, gallbladder disease, hepatitis/jaundice, appendicitis, colitis, hernia?

• Ever had any abdominal operations? Please describe.

• Any problems after surgery?

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

8. Medications

• Which medications are you taking currently?

• How about alcohol—how much would you say you drink each day? Each week? When was your last alcoholic drink?

• How about cigarettes—do you smoke? How many packs per day? For how long?

Peptic ulcer disease occurs with frequent use of nonsteroidal antiinflammatory drugs (NSAIDs), alcohol, smoking, and Helicobacter pylori infection.

9. Nutritional assessment

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

• Which fresh food markets are located in your neighborhood?

Nutritional assessment via 24-hour recall (see Chapter 12 for full discussion).

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

Additional History for Infants and Children

1. Are you breastfeeding or bottle-feeding the baby? If bottle-feeding, how does baby tolerate the formula?

2. Which table foods have you introduced? How does the infant tolerate the food?

Consider a new food as a possible allergen. Adding only one new food at a time to the infant’s diet helps identify allergies.

3. How often does your toddler/child eat? Does he or she eat regular meals? How do you feel about your child’s eating problems?

• Please describe all that your child had to eat yesterday, starting with breakfast. Which foods does the child eat for snacks?

Irregular eating patterns are common and a source of parental anxiety. As long as the child shows normal growth and development and only nutritious foods are offered, parents may be reassured.

• Does toddler/child ever eat nonfoods: grass, dirt, paint chips?

Pica: Although a toddler may attempt nonfoods at some time, he or she should recognize edibles by age 2 years.

4. Does your child have constipation? How long?

Constipation may affect up to 30% of children. This is almost always functional, meaning the bowel is healthy, but there may be inadequate fiber and fluids, inactivity, stress, medications, or other contributing diseases. Children may also ignore the urge to defecate or withhold or delay defecation, especially during toilet training. 18

• What is the number of stools/day? Stools/week?

• How much water, juice is in the diet?

• Does the constipation seem to be associated with toilet training?

• What have you tried to treat the constipation?

5. Does the child have abdominal pain? Please describe what you have noticed and when it started.

Pain is hard to assess with children. Many conditions of unrelated organ systems have vague abdominal pain (e.g., otitis media). They cannot articulate specific symptoms and often focus on “the tummy.” Abdominal pain accompanies inflammation of the bowel, constipation, urinary tract infection, and anxiety.

6. For the overweight child: How long has weight been a problem?

• At what age did the child first seem overweight? Did any change in diet pattern occur then?

• Describe the diet pattern now.

Reduced physical activity and food marketing practices contribute to current obesity epidemic.

• Do any others in family have a similar problem?

Family history of obesity.

• How does child feel about his or her own weight?

Assess body image and social adjustment.

Additional History for Adolescents

1. What do you eat at regular meals? Do you eat breakfast? What do you eat for snacks?

Adolescent takes control of eating and may reject family values (e.g., skipping breakfast, consuming junk foods and soda pop). The only control parents have is what food is in the house.

• How many calories do you figure you consume?

You probably cannot change adolescent eating patterns, but you can supply nutritional facts.

2. What is your exercise pattern?

Boys need an average 4000 cal/day to maintain weight; more calories if exercise is pursued. Girls need 20% fewer calories and the same nutrients as boys. Fast food is high in fat, calories, and salt and has low fiber.

3. If weight is less than body requirements: How much have you lost? By diet, exercise, or how?

Screen any extremely thin teenager for anorexia nervosa, a serious psychosocial disorder that includes loss of appetite, voluntary starvation, and grave weight loss. This person may augment weight loss by purging (self-induced vomiting) and use of laxatives.

• How do you feel? Tired, hungry? How do you think your body looks?

Denial of these feelings is common. Although thin, teens may insist they look fat, “disgusting.” Distorted body image.

• What is your activity pattern?

The adolescent with anorexia may have healthy activity and exercise but often is hyperactive.

• Is the weight loss associated with any other body change, such as menstrual irregularity?

Amenorrhea is common with anorexia nervosa.

• What do your parents say about your eating? What do your friends say?

This is a family problem involving control issues. Anyone at risk warrants immediate referral to a physician and mental health professional.

Additional History for the Aging Adult

1. How do you acquire your groceries and prepare your meals?

Assess risk for nutritional deficit: limited access to grocery store, income, or cooking facilities; physical disability (impaired vision, decreased mobility, decreased strength, neurologic deficit).

2. Do you eat alone or share meals with others?

Assess risk for nutritional deficit if living alone; may not bother to prepare all meals; social isolation; depression.

3. Please tell me all that you had to eat yesterday, starting with breakfast.

Note: 24-hour recall may not be sufficient because daily pattern may vary. Attempt week-long diary of intake. Food pattern may differ during the month if monthly income (e.g., Social Security check) runs out.

• Do you have any trouble swallowing these foods?

• What do you do right after eating: walk, take a nap?

4. How often do your bowels move?

• If the person reports constipation: What do you mean by constipation? How much liquid is in your diet? How much bulk or fiber?

• Do you take anything for constipation, such as laxatives? Which ones? How often?

• Which medications do you take?

Consider GI side effects (e.g., nausea, upset stomach, anorexia, dry mouth).

Objective Data

Preparation

The lighting should include a strong overhead light and a secondary stand light. Expose the abdomen so that it is fully visible. Drape the genitalia and female breasts.

The following measures enhance abdominal wall relaxation:

• The person should have emptied the bladder, saving a urine specimen if needed.

• Keep the room warm to avoid chilling and tensing of muscles.

• Position the person supine, with the head on a pillow, the knees bent or on pillow, and the arms at the sides or across the chest. (Note: Discourage the person from placing his or her arms over the head because this tenses abdominal musculature.)

• To avoid abdominal tensing, the stethoscope endpiece must be warm, your hands must be warm, and your fingernails must be very short.

• Inquire about any painful areas. Examine such an area last to avoid any muscle guarding.

• Finally, learn to use distraction: Enhance muscle relaxation through breathing exercises; emotive imagery; your low, soothing voice; by engaging in conversation; or by having the person relate their abdominal history while you palpate.

Equipment Needed

Stethoscope

Alcohol wipe (to clean endpiece)

Normal Range of Findings Abnormal Findings

Inspect the Abdomen

Contour

Stand on the person’s right side and look down on the abdomen. Then stoop or sit to gaze across the abdomen. Your head should be slightly higher than the abdomen. Determine the profile from the rib margin to the pubic bone. The contour describes the nutritional state and normally ranges from flat to rounded (Fig. 22.7).

22.7

Scaphoid abdomen caves in. Protuberant abdomen indicates abdominal distention (see Table 22.1, p. 563).

Symmetry

Shine a light across the abdomen toward you or lengthwise across the person. The abdomen should be symmetric bilaterally (Fig. 22.8). Note any localized bulging, visible mass, or asymmetric shape. Even small bulges are highlighted by shadow. Step to the foot of the examination table to recheck symmetry.

22.8

Bulges, masses.

Hernia—Protrusion of abdominal viscera through abnormal opening in muscle wall (see Table 22.4, Abnormalities on Inspection, p. 567).

Sister Mary Joseph nodule is a hard nodule in umbilicus that occurs with metastatic cancer of stomach, large intestine, ovary, or pancreas.15

Ask the person to take a deep breath to further highlight any change. The abdomen should stay smooth and symmetric. Or ask the person to perform a sit-up without pushing up with their hands.

Note any localized bulging.

Hernia or enlarged liver or spleen may show.

Umbilicus

Normally it is midline and inverted, with no sign of discoloration, inflammation, or hernia. It becomes everted and pushed upward with pregnancy.The umbilicus is a common site for piercings. The site should not be red or crusted.

Everted with ascites or underlying mass (Table 22.1).

Deeply sunken with obesity.

Enlarged, everted with umbilical hernia.

Bluish periumbilical color occurs (though rarely) with intraperitoneal bleeding (Cullen sign).15

Skin

The surface is smooth and even, with homogeneous color. This is a good area to judge pigment because it is often protected from sun.

Redness with localized inflammation.

Jaundice (shows best in natural daylight).

Skin glistening and taut with ascites.

One common pigment change is striae (lineae albicantes)—silvery white, linear, jagged marks about 1 to 6 cm long (Fig. 22.9). They occur when elastic fibers in the reticular layer of the skin are broken after rapid or prolonged stretching as in pregnancy or excessive weight gain. Recent striae are pink or blue; then they turn silvery white.

22.9 Striae.

Striae also occur with ascites.

Striae look purple-blue with Cushing syndrome (excess adrenocortical hormone causes the skin to be fragile and easily broken from normal stretching).

Pigmented nevi (moles)—circumscribed brown macular or papular areas—are common on the abdomen. Unusual color or change in shape of mole (see Chapter 13).Petechiae.

Normally no lesions are present, although you may note well-healed surgical scars. If a scar is present, draw its location in the person’s record, indicating the length in centimeters (Fig. 22.10). (Note: Infrequently a person may forget a past operation when providing the history. If you note a scar now, ask about it.) A surgical scar alerts you to the possible presence of underlying adhesions and excess fibrous tissue.

22.10

Spider angiomas occur with portal hypertension or liver disease.

Lesions, rashes (see Chapter 13).

Underlying adhesions are inflammatory bands that connect opposite sides of serous surfaces after trauma or surgery.

Veins usually are not seen, but a fine venous network may be visible in thin persons.

Prominent, dilated veins (caput medusae) occur with portal hypertension, cirrhosis, ascites, or vena caval obstruction.

Veins are more visible with malnutrition as a result of thinned adipose tissue.

Good skin turgor reflects adequate hydration. Gently pinch up a fold of skin; then release to note the immediate return of the skin to original position. Poor turgor occurs with dehydration, which often accompanies GI disease.

Pulsation or Movement

Normally you may see the pulsations from the aorta beneath the skin in the epigastric area, particularly in thin people with good muscle wall relaxation. Respiratory movement also shows in the abdomen, particularly in males. Finally, waves of peristalsis sometimes are visible in very thin people. They ripple slowly and obliquely across the abdomen.

Marked pulsation of aorta occurs with widened pulse pressure (e.g., hypertension, aortic insufficiency, thyrotoxicosis) and aortic aneurysm.

Marked visible peristalsis, together with a distended abdomen, indicates intestinal obstruction.

Hair Distribution

The pattern of pubic hair growth normally has a diamond shape in adult males and an inverted triangle shape in adult females (see Chapters 25 and 27). Patterns alter with endocrine or hormone abnormalities, chronic liver disease.

Demeanor

A comfortable person is relaxed quietly on the examining table and has a benign facial expression and slow, even respirations.

Restlessness and constant turning to find comfort occur with the colicky pain of gastroenteritis or bowel obstruction (see Table 22.2, p. 565, and Table 22.3, p. 566).

Absolute stillness, resisting any movement, occurs with the pain of peritonitis.

Knees flexed up, facial grimacing, and rapid, uneven respirations also indicate pain.

Auscultate Bowel Sounds and Vascular Sounds

Depart from the usual examination sequence and auscultate the abdomen next. This is done because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.a Use the diaphragm endpiece because bowel sounds are relatively high-pitched. Hold the stethoscope lightly against the skin; pushing too hard may stimulate more bowel sounds (Fig. 22.11). Begin in the RLQ at the ileocecal valve area because bowel sounds normally are always present here.

22.11

Bowel Sounds

Note the character and frequency of bowel sounds. Although the origin of bowel sounds is not fully understood, they may originate from the movement of air and fluid within the stomach and large and small intestine. A wide range of normal sounds can occur. Normal bowel sounds are high-pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5 to 30 times per minute. Do not bother to count them. In addition, because the sounds radiate widely over the abdomen, the gurgle you hear in the RLQ may originate in the stomach. Therefore listening in all four quadrants is not necessary.6,15 Just judge if they are present or are hypoactive or hyperactive. One type of hyperactive bowel sounds is fairly common: hyperperistalsis, when you feel your “stomach growling,” termed borborygmus.

Bowel sound interpretation is highly subjective and can vary widely among clinicians, and bowel sounds are likely not a reliable indicator of bowel function in many circumstances.6,7 For example, should you withhold oral intake following following colorectal surgery? Other indicators may be more reliable (tolerance of oral intake, passage of stool, and lack of abdominal distension).3,10 A perfectly “silent abdomen” is uncommon; you must listen for 5 minutes by your watch before deciding whether bowel sounds are completely absent.

Two distinct patterns of abnormal bowel sounds may occur:

1. Hyperactive sounds are loud, high-pitched, rushing, tinkling sounds that signal increased motility.

2. Hypoactive or absent sounds follow abdominal surgery or with inflammation of the peritoneum (see Table 22.5, Abnormal Bowel Sounds, p. 568, and Table 22.2, p. 565).

Vascular Sounds

As you listen to the abdomen, note the presence of any vascular sounds or bruits. Using firmer pressure, check over the aorta, renal arteries, iliac, and femoral arteries, especially in people with hypertension (Fig. 22.12). Usually no such sound is present. However, about 4% to 20% of healthy people (usually younger than 40 years) may have a normal bruit usually coming from the celiac artery.15 It is systolic, medium to low in pitch, and heard between the xiphoid process and the umbilicus.

22.12

A cut-out pictorial reference of a upper human body where the parts are marked as follows : Aorta is marked in the middle, left to the aorta is left renal artery, left to the navel is iliac artery, below the iliac artery is femoral artery.

Note location, pitch, and timing of a vascular sound.

A systolic bruit is a pulsatile blowing sound and occurs with stenosis, partial occlusion, or aneurysm of an artery.

Venous hum and peritoneal friction rub are rare (see Table 22.6, Friction Rubs and Vascular Sounds, p. 569).

For safe practice, do NOT use auscultation of the abdomen for the correct placement of nasogastric tubes. Despite evidence showing that auscultation of an air bolus is not adequate to determine placement in the stomach or lung, you may see some nurses still practicing this method. Current evidence mandates confirming initial placement by chest x-ray and supports continuing assessment by measuring the external portion of the tube and testing the pH of stomach aspirates (pH less than 5.5 is acceptable). Ongoing visualization of gastric aspirates is also important to ensure that the tube has not migrated; fasting gastric secretions range from clear to green or brown.27 The auscultation method can wrongly suggest that the feeding tube is correctly placed in the stomach; serious harm or even fatality can result from administering tube-feeding material or medications into the lung.

Percussion

Percuss to assess the relative density of abdominal contents and to screen for abnormal fluid or masses.

General Tympany

First percuss lightly in all four quadrants to determine the prevailing amount of tympany and dullness (Fig. 22.13). Move clockwise. Tympany should predominate because air in the intestines rises to the surface when the person is supine.

Dullness occurs over a distended bladder, adipose tissue, fluid, or a mass.

Hyperresonance is present with gaseous distention.

22.13

Liver Span, Splenic Dullness, and Bladder Percussion

Traditionally, the upper and lower borders of the liver were identified by percussion to estimate liver span. This technique of measuring liver span underestimates the true liver size because clinicians place the upper border too low and/or the lower border too high.15 Percussion also yields highly variable results between examiners and frequently does not identify hepatomegaly even when present. Therefore, this examination technique is not recommended. Please see information on palpation of the liver on p. 550 for further assessment.Screening for splenomegaly through percussion of splenic dullness is omitted because detection through palpation is more reliable.15

Detection of a distended bladder through percussion is also omitted due to unreliability.15 Bedside bladder scanning with ultrasound is commonly used to estimate bladder volume.

The upper liver border is overestimated if chronic obstructive lung disease is present, and both upper and lower edges are obscured if obesity or ascites is present.

Costovertebral Angle Tenderness

Indirect fist percussion causes the tissues to vibrate instead of producing a sound. To assess the kidney, place one hand over the 12th rib at the costovertebral angle on the back (Fig. 22.14). Thump that hand with the ulnar edge of your other fist. The person normally feels a thud but no pain. (Although this step is explained here with percussion techniques, its usual sequence in a complete examination is with thoracic assessment, when the person is sitting up and you are standing behind.)

22.14

Sharp pain occurs with inflammation of the kidney or perinephric area, as in pyelonephritis.

Palpate Surface and Deep Areas

Perform palpation to judge the size, location, and consistency of certain organs and to screen for an abnormal mass or tenderness. Review comfort measures on p. 542. Because most people are naturally inclined to protect the abdomen, you need to use additional measures to enhance complete muscle relaxation.

1. Bend the person’s knees.

2. Keep your palpating hand low and parallel to the abdomen. Holding the hand high and pointing down would make anyone tense up.

3. Teach the person to breathe slowly (in through the nose and out through the mouth).

4. Keep your own voice low and soothing. Conversation may relax the person.

5. Try “emotive imagery.” For example, you might say, “Now I want you to imagine that you are dozing on the beach, with the sun warming your muscles and the sound of the waves lulling you to sleep. Let yourself relax.”

6. With a very ticklish person, keep the person’s hand under your own with your fingers curled over his or her fingers. Move both hands around as you palpate; people are not ticklish to themselves.

7. Alternatively perform palpation just after auscultation. Keep the stethoscope in place and curl your fingers around it, palpating as you pretend to auscultate. People do not perceive a stethoscope as a ticklish object. You can slide the stethoscope out when the person is used to being touched.

Light and Deep Palpation

Begin with light palpation. With the first four fingers close together, depress the skin about 1 cm (Fig. 22.15). Make a gentle rotary motion, sliding the fingers and skin together. Then lift the fingers (do not drag them) and move clockwise to the next location around the abdomen. The objective here is not to search for organs but to form an overall impression of the skin surface and superficial musculature. Save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination.

22.15

Muscle guarding.

Rigidity.

Large masses.

Tenderness.

As you circle the abdomen, discriminate between voluntary muscle guarding and involuntary rigidity. Voluntary guarding occurs when the person is cold, tense, or ticklish. It is bilateral, and you will feel the muscles relax slightly during exhalation. Use the relaxation measures to try to eliminate this type of guarding, or it will interfere with deep palpation. If the rigidity persists, it is probably involuntary. Involuntary rigidity is a constant, boardlike hardness of the muscles. It is a protective mechanism accompanying acute inflammation of the peritoneum. It may be unilateral, and the same area usually becomes painful when the

Now perform deep palpation using the technique described earlier but push down about 5 to 8 cm (2 to 3 inches) (Fig. 22.16). Moving clockwise, explore the entire abdomen.

22.16

person increases intra-abdominal pressure by attempting a sit-up.

To overcome the resistance of a very large or obese abdomen, use a bimanual technique. Place your two hands on top of one another (Fig. 22.17). The top hand does the pushing; the bottom hand is relaxed and can concentrate on the sense of palpation. With either technique note the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses.

22.17

Making sense of what you are feeling is more difficult than it looks. Inexperienced examiners complain that the abdomen “all feels the same,” as if they are pushing their hand into a soft sofa cushion. It helps to memorize the anatomy and visualize what is under each quadrant as you palpate. Also remember that some structures are normally palpable, as illustrated in Fig. 22.18.

22.18

A cut-out illustration of female upper body is presented with their parts as follows : The middle bone in the chest is marked as xiphoid process, "Normal liver edge" is marked at the bottom of the liver, "right kidney lower pole" a little extension behind the liver, "pulsatile aorta "runs through the middle of the body, "rectus muscles, lateral borders" are around the right hip region, "sacral promontory" is around the navel region, ascending colon, "cecum" is at the end of ascending colon, "sigmoid colon" is on the left, "uterus (gravid)", full bladder.

Mild tenderness normally is present when palpating the sigmoid colon in the left lower quadrant. Any other tenderness should be investigated. Tenderness occurs with local inflammation, inflammation of the peritoneum or underlying organ, and with an enlarged organ whose capsule is stretched.

If you identify a mass, first distinguish it from a normally palpable structure or an enlarged organ. Then note the following:

1. Location

2. Size

3. Shape

4. Consistency (soft, firm, hard)

5. Surface (smooth, nodular)

6. Mobility (including movement with respirations)

7. Pulsatility

8. Tenderness

Liver

Next palpate for specific organs, beginning with the liver in the RUQ (Fig. 22.19). Place your left hand under the person’s back parallel to the 11th and 12th ribs and lift up to support the abdominal contents. Place your right hand on the RUQ, with fingers parallel to the midline. Push deeply down and under the right costal margin. Ask the person to breathe slowly. With every exhalation, move your palpating hand up 1 or 2 cm. It is normal to feel the edge of the liver bump your fingertips as the diaphragm pushes it down during inhalation. It feels like a firm, regular ridge. Often the liver is not palpable and you feel nothing firm.

22.19

One variation occurs in people with chronic emphysema, in which the liver is displaced downward by the hyperinflated lungs. Although you palpate the lower edge well below the right costal margin, the overall size is still within normal limits. Except with a depressed diaphragm, a liver palpated more than 1 to 2 cm below the right costal margin is enlarged. Record the number of centimeters it descends and note its consistency (hard, nodular) and tenderness (see Table 22.7, Palpation of Enlarged Organs, p. 570). For example, an abnormally firm liver may indicate cirrhosis.15

Hooking Technique.An alternative method of palpating the liver is to stand up at the person’s shoulder and swivel your body to the right so that you face the person’s feet (Fig. 22.20). Hook your fingers over the costal margin from above. Ask the person to take a deep breath. Try to feel the liver edge bump your fingertips.

22.20

Scratch Test.This traditional technique uses auscultation to detect the lower border of the liver. Place the stethoscope over the xiphoid process while lightly stroking the skin with one finger up the MCL from the RLQ and parallel to the liver border. When you reach the liver edge, the sound is magnified in the stethoscope. However, there are many variations in the technique, and evidence is mixed as to its value.15 One study found moderate agreement between the results by scratch test and ultrasound. The researchers recommend the scratch test if the abdomen is distended, obese, or too tender for palpation or if muscles are rigid or guarded.9

Spleen

Normally the spleen is not palpable and must be enlarged 3 times its normal size to be felt. To search for it, reach your left hand over the abdomen and behind the left side at the 11th and 12th ribs (Fig. 22.21A). Lift up for support. Place your right hand obliquely on the LUQ with the fingers pointing toward the left axilla and just inferior to the rib margin. Push your hand deeply down and under the left costal margin and ask the person to take a deep breath. You should feel nothing firm. Imaging by ultrasound is more precise.

22.21

The spleen enlarges with mononucleosis, trauma, leukemia and lymphomas, portal hypertension, and HIV infection (see Table 22.7). Consider malaria in persons with fever and splenomegaly returning from travel to areas where malaria is endemic. If you feel an enlarged spleen, refer the person but do not continue to palpate it. An enlarged spleen is friable and can rupture easily with overpalpation.

Describe the number of centimeters that it extends below the left costal margin.

When enlarged, the spleen slides out and bumps your fingertips. It can grow so large that it extends into the lower quadrants. When this condition is suspected, start low so that you will not miss it. An alternative position is to roll the person onto their right side to displace the spleen more forward and downward (Fig. 22.21B). Then palpate as described earlier.

Kidneys

Search for the right kidney by placing your hands together in a “duck-bill” position at the person’s right flank (Fig. 22.22A). Press your two hands together firmly (you need deeper palpation than that used with the liver or spleen), and ask the person to take a deep breath. In most people you will feel no change. Occasionally you may feel the lower pole of the right kidney as a round, smooth mass that slides between your fingers. Either condition is normal.

22.22

(A) A cut-out top angle view of a patient's upper body where a left hand is placed underneath the right hip and the right hand is pressed on top of the right hip. (B) Left hand is placed underneath the left hip and the right hand is pressed on top of the left hip.

Enlarged kidney.

Kidney mass.

The left kidney sits 1 cm higher than the right kidney and is not palpable normally. Search for it by reaching your left hand across the abdomen and behind the left flank for support (Fig. 22.22B). Push your right hand deep into the abdomen and ask the person to breathe deeply. You should feel no change with the inhalation.

Aorta

Using your opposing thumb and fingers, palpate the aortic pulsation in the upper abdomen slightly to the left of midline (Fig. 22.23). Normally it is 2.5 to 4 cm wide in the adult and pulsates in an anterior direction.

22.23

Widened with abdominal aortic aneurysm (see Table 22.6, p. 569, and Table 22.7, p. 570).

Prominent lateral pulsation with aortic aneurysm pushes the examiner’s two fingers apart. Palpation may have poor accuracy detecting aneurysm due to interference of the skin and adipose tissue, as well as the retroperitoneal location of the aorta.15