Abdomen

Chapter 22: Abdomen Overview:

Peritoneum

  • The peritoneum is a serous membrane that lines the abdominal cavity and covers the abdominal organs. It acts as a protective layer and secretes a lubricating fluid to reduce friction. The peritoneum supports these organs and helps maintain their position in the abdominal cavity.

    • Covered Organs Include:

      • Spleen: Plays a crucial role in filtering blood and immune response.

      • Liver: Vital for detoxification, metabolism, and production of important biochemicals necessary for digestion.

      • Stomach: Key in breaking down food and initiating digestion with gastric juices.

      • Gallbladder: Stores and concentrates bile, aiding in fat digestion.

Viscera

  • Refers to the internal abdominal organs, particularly those within the gastrointestinal tract. This includes:

    • Small intestine: Absorbs nutrients and minerals from food.

    • Ascending colon, descending colon, cecum, appendix, sigmoid colon: Responsible for processing waste and absorbing water.

    • Bladder: Stores urine, played critical roles in waste excretion and fluid balance in the body.

Right Upper Quadrant (RUQ)

  • Contains several important structures crucial for bodily functions, including:

    • Liver: Largest internal organ involved in metabolism, detoxification, and bile production.

    • Gallbladder: Stores bile produced by the liver.

    • Duodenum: First part of the small intestine, plays role in chemical digestion.

    • Head of pancreas: Produces enzymes crucial for digestion and insulin for blood sugar regulation.

    • Right kidney & adrenal gland: Regulates metabolism, immunity, and blood pressure.

    • Part of ascending and transverse colon: Involved in the absorption of water and salts, and elimination of solid waste.

Left Upper Quadrant (LUQ)

  • Contains:

    • Stomach: Continues digestion of food, mixing it with gastric juices.

    • Spleen: Involved in immune response and removal of old red blood cells.

    • Left lobe of liver: Part of the liver involved in metabolism and detoxification.

    • Body of pancreas: Produces enzymes aiding digestion and regulates blood glucose levels.

    • Left kidney & adrenal gland: Similar functions as the right kidney, contributing to homeostasis.

    • Part of transverse and descending colon: Important for waste processing and absorption.

Right Lower Quadrant (RLQ)

  • Contains critical reproductive and excretory structures:

    • Appendix: Plays a role in gut microbiota but can lead to appendicitis if inflamed.

    • Right ovary & fallopian tube: Female reproductive organs responsible for ovum transport and hormone production.

    • Right ureter: Conducts urine from the kidney to the bladder.

    • Right spermatic cord: Contains blood vessels and nerves supplying the testes in males.

Left Lower Quadrant (LLQ)

  • Contains:

    • Sigmoid colon: Last part of the colon leading to the rectum, involved in waste formation and expulsion.

    • Left ovary & fallopian tube: Functions similarly to the right side in the reproductive process.

    • Left ureter: Transports urine from the left kidney to the bladder.

    • Left spermatic cord: Corresponds to the right side for male reproductive structures.

Newborns

  • Characteristics: The umbilical cord is prominent, and the abdominal structure is different as organs are not yet fully mature.

Early Childhood

  • Development: The abdominal wall is less muscular, making organs easier to palpate. This is crucial for assessments and understanding growth patterns.

Older Adults

  • Changes: Salivation decreases, leading to dry mouth. This impacts appetite and nutritional intake.

    • Gastrointestinal Changes: Esophageal emptying and gastric acid secretion slow down, causing potential digestive issues.

    • Increased incidence of gallstones: Due to changes in bile composition and concentration.

    • Liver Size: While liver size decreases, most functions remain normal; however, drug metabolism is affected, potentially complicating medication management.

    • Common Ailments: Aging often results in frequent constipation, which must be monitored closely.

Subjective Data:

  • Assessing the patient's appetite, any dysphagia (difficulty in swallowing), signs of food intolerance, and any reports of abdominal pain.

  • Gathering information on nausea and vomiting occurrences, bowel habits, past abdominal history, current medications, and conducting a nutritional assessment to evaluate overall health.

Nurse Action Example

  • 24-hour recall: A method where patients are asked to recall everything consumed in the last 24 hours to evaluate their nutritional intake. Other methods include food frequency questionnaires, maintaining a food diary, and direct observation of food intake to gather comprehensive dietary information.

Questions to Consider:

  • Are you breastfeeding or bottle-feeding? Assess how the infant is tolerating feeding.

  • Determine the frequency of meals for toddlers and children for proper growth tracking.

  • Investigate the number and frequency of stools per week to gauge digestive health.

  • Gather information about hydration - particularly water and juice intake - for developmental support.

Steps Before Examination

  • Ensure the abdomen is exposed while keeping genitalia and breasts covered to maintain patient dignity.

  • Patient comfort is paramount; enhance relaxation of the abdominal wall to facilitate examination.

  • Empty bladder: Advisable before examination, consider collecting a specimen if necessary.

  • Warm the stethoscope: To improve patient comfort during auscultation.

  • Examination Order: Auscultate before palpation and percussion, examine painful areas last to minimize discomfort.

Sequence of Techniques

  • The correct order for abdominal examination is crucial for accuracy and patient comfort: Inspection, Auscultation, Percussion, and Palpation.

Key Elements

Contour:

  • Observe the shape and symmetry of the abdomen, noting any abnormalities.

  • Umbilicus:

    • Should be midline, typically inverted with no discoloration; consider everted umbilicus during pregnancy.

  • Skin:

    • Check for pulsation or movement; expecting to see aorta's pulsations in the epigastric area can indicate various health issues.

Common Forms:

  • Flat: Normal, often seen in healthy individuals.

  • Scaphoid: Inwardly curved, may indicate malnutrition or dehydration.

  • Rounded: Indicates possible obesity or conditions like ascites.

  • Protuberant: Suggests underlying issues such as pregnancy, tumors, or fluid accumulation.

Importance

  • Auscultation is performed first to avoid altering peristalsis results; this is vital for an accurate diagnosis.

  • Use the diaphragm for detecting bowel sounds; start in the RLQ to ensure normal sounds presence.

Findings

  • Types of sounds include:

    • Normoactive: Normal, expected bowel activity.

    • Hypoactive: Reduced sounds, may suggest obstruction or ileus.

    • Hyperactive: Increased sounds, often indicates diarrhea or increased bowel activity.

    • Absent: Requires further investigation, indicating possible ileus or bowel obstruction.

Procedure

  • Use a bell for vascular sounds; firm pressure is required over major arteries, especially in hypertensive patients:

    • Aorta: Main vessel supplying blood to the body.

    • Renal arteries: Supply blood to the kidneys.

    • Iliac and femoral arteries: Supply the lower limbs, listening for bruits that may indicate vascular disease.

Purpose

  • To assess the relative density of abdominal contents, locate organs, and screen for abnormal fluid or masses.

Key Findings

  • General tympany should predominate, indicating air in intestines; indicates normal gas support.

  • Dullness over organs such as liver and spleen indicates their presence, needing further evaluation for abnormalities.

Liver Span Assessment

  • Measure in the right midclavicular line:

    • Begin at lung resonance and percussion until a dull sound is noted; this helps assess liver size.

    • Normal liver span: Ranges from 6-12 cm in adults, variations may indicate pathology.

Splenic Dullness

  • Percuss for dull notes in the 9th to 11th intercostal space to assess spleen size.

  • Area of splenic dullness normally is usually less than 7 cm in adult

Assessment

  • Percuss at the costovertebral angle; expect a thud but no pain under normal circumstances.

  • Sharp pain with percussion may indicate kidney inflammation requiring immediate medical evaluation.

Technique: Light Palpation:

  • Use the first four fingers to depress the skin about 1 cm, focusing on an overall impression rather than locating specific organs.

  • Save examination of tender areas until last to minimize discomfort.

Findings

  • Feel for:

    • Softness and nontender surfaces.

    • Guarding: Determine if it is voluntary (muscle tension) vs. involuntary (indicative of underlying pathology).

Deep Palpation:

  • Push down 2-3 inches, possibly employing a bimanual technique for larger abdomens; this provides a more thorough examination.

Identify mass characteristics:

  • Location, Size, Shape, Consistency, Surface texture, Mobility, Tenderness

Palpation of Liver:

  • Place your hand under the patient's right rib cage and push upwards while simultaneously palpating the liver edge with your other hand to assess its size and consistency.

  • Note any tenderness or irregularities during palpation. Instruct the patient to take a deep breath, as this may help to bring the liver down into the palpating hand, allowing for a more accurate assessment.

Palpation of Spleen:

  • Spleen typically is not palpable without significant enlargement (three times normal). Palpation technique involves:

    • Left hand on the abdomen behind the rib; Right hand on LUQ to feel the spleen as the patient inhales.

    • Place the left hand over the abdomen behind the 11th/12th rib on the left side

Palpation of Kidneys:

  • Kidneys are typically not palpable unless enlarged; they can be felt by placing hands in a "duck-bill" formation during deep breathing.

Assessment

  • Palpate the aorta for pulsation; it is normally measuring 2.5 - 4 cm wide and pulsates anteriorly. Changes in size could indicate vascular issues.

Rebound Tenderness:

  • Conduct at the end of the examination. Pain during release indicates peritoneal inflammation (referred to as Blumberg sign), suggesting conditions such as appendicitis if found in the RLQ.

Indicators of Concern

  • Notable Abnormal findings may include:

    • Ascites: Fluid accumulation in the abdominal cavity, often due to liver disease.

    • Hernias: Such as umbilical, epigastric, or incisional; protrusion may suggest weakness in the abdominal wall.

    • Diastasis recti: Separation of abdominal muscles; significant in childbirth.

    • Arterial bruit: Suggestive of turbulent blood flow, often needing further investigation.

    • Enlarged organs (liver, spleen, kidney): Indicates underlying pathology needing immediate attention.

Appendicitis Assessment

  • Important to ask patients to indicate pain location accurately and palpate that region first to avoid exacerbating discomfort.

Interpretation

  • The presence of a bruit in the epigastric area may suggest multiple potential conditions, including:

    • Bowel Impaction: May lead to obstruction and related symptoms.

    • Abdominal Aortic Aneurysm: Life-threatening condition requiring urgent assessment.

    • Kidney Infection: Impacting renal function.

    • Enlarged Liver: Suggesting liver disease or hepatomegaly issues requiring thorough evaluation.