Health Assessment

CHAPTER 20 - ABDOMINAL ASSESSMENT

ABDOMINAL CAVITY

  • Definition and Structure:

    • The abdominal cavity is a large oval cavity.

    • Extends from the xiphoid process down to the superior margin of the pubic bone.

    • Composed of four layers of large flat muscles forming the ventral abdominal wall.

    • Muscles joined at the midline by a structure called the linea alba.

GASTROINTESTINAL ORGANS

  • Functions:

    • Responsible for key processes: ingestion, absorption, digestion, and elimination of food.

  • Main Gastrointestinal Organs:

    • Esophagus

    • Stomach

    • Small Intestines

    • Colon (Large Intestine)

  • Accessory Organs:

    • Liver

    • Pancreas

    • Gallbladder

GENITOURINARY ORGANS

  • Functions:

    • Responsible for controlling blood pressure (BP), stimulating red blood cell (RBC) production, filtering, and removing waste products (urine).

  • Genitourinary Organs:

    • Kidneys

    • Ureters

    • Bladder

  • Genital Systems:

    • Male: Spermatic cord.

    • Female: Uterus and ovaries.

BLOOD VESSELS, PERITONEUM, AND MUSCLES STRUCTURE AND FUNCTION

  • Blood Supply:

    • The aorta and branching arteries/veins supply oxygenated blood to the lower half of the body.

    • Spleen stores RBCs and platelets.

    • The aorta is located at the left midline of the upper abdomen.

    • Approximately 2 cm below the umbilicus, the aorta bifurcates into two femoral arteries.

  • Peritoneum:

    • A membrane that covers and holds organs in place.

    • Fluid between the layers allows for smooth movement within the abdominal cavity.

  • Mesentery:

    • Blood supply from the dorsal aorta supplies blood vessels and nerves to the intestinal tract.

  • Muscles:

    • Provide protection and support for the digestive system.

REFERENCE LINES: FOUR QUADRANTS

  • The abdomen is divided into four quadrants for assessment:

    • 1. Right Upper Quadrant (RUQ)

    • 2. Right Lower Quadrant (RLQ)

    • 3. Left Upper Quadrant (LUQ)

    • 4. Left Lower Quadrant (LLQ)

INGESTION AND DIGESTION

  • Process:

    • Ingestion begins in the mouth with mastication (chewing).

    • Food travels down the esophagus through peristaltic movements into the stomach.

    • In the stomach, food is churned into chyme (liquid-digested food) by digestive juices and hydrochloric acid.

  • Types of Digestion:

    • Mechanical Digestion:

    • Breakdown of food through chewing, peristalsis, and churning.

    • Chemical Digestion:

    • Breakdown of food through metabolic reactions involving hydrochloric acid, enzymes, and hormones.

ABSORPTION OF NUTRIENTS

  • Location:

    • Main absorption occurs in the small intestines.

  • Parts of the Small Intestine:

    • Duodenum:

    • The first part where pancreatic juices and bile are secreted into the chyme, making nutrients available for absorption.

    • Jejunum and Ileum:

    • The second and third parts that absorb nutrients through villi lining the intestinal walls.

ELIMINATION

  • Process:

    • Any food not absorbed by the small intestine moves to the large intestine (colon).

    • The colon primarily absorbs some electrolytes and water.

    • Remaining waste products are excreted as feces in about 48 hours.

RISK REDUCTION AND HEALTH PROMOTION

  • Risk Reduction:

    • Focus on conditions like colorectal cancer, food-borne illness, hepatitis A, B, C.

    • Hepatitis vaccinations A and B recommended.

  • Health Promotion:

    • Nutritional counseling, food safety education, and regular screenings are critical.

    • Specific follow-up guidelines after age 45 include:

    • Colonoscopy every 10 years.

    • CT colonography every 5 years.

    • Flexible sigmoidoscopy every 5 years.

    • Yearly fecal immunochemical test.

    • Yearly fecal occult blood test.

    • Stool DNA test every 3 years.

COLORECTAL CANCER AND HEPATITIS

  • Colorectal Cancer:

    • Third most commonly diagnosed cancer and third leading cause of cancer death.

    • Incidence is decreasing in persons over 55 years.

    • Modifiable Risk Factors include:

    • Sedentary lifestyle

    • Intake of red and processed meats

    • Obesity

    • Smoking and excessive alcohol use.

  • Hepatitis:

    • Hepatitis A is transmitted via the oral-fecal route.

    • Hepatitis B and C are transmitted via blood and body fluid exposure, which can lead to chronic disease.

    • Vaccinations are recommended for all infants, especially for individuals potentially exposed to blood or unsanitary conditions.

    • Goals include education, early detection, treatment, screenings, and immunizations.

FOOD-BORNE ILLNESS AND ALLERGIES

  • Causes:

    • Improper storage and handling of food.

    • Most affected populations: young, elderly, and immunocompromised individuals.

  • Allergy Reactions:

    • Symptoms can develop between minutes to 2 hours post-exposure, including:

    • Lip/tongue swelling

    • Puritis and swelling

    • Laryngeal edema

    • Nausea

    • Abdominal cramping

    • Vomiting and diarrhea

    • Anaphylaxis

  • Goals:

    • Reduce infections from food-borne pathogens and death from anaphylactic shock due to food allergies.

    • Key strategies include food labeling, food preparation, storage, and promoting handwashing practices.

SUBJECTIVE DATA

  • Family and Past Medical History:

    • Inquiry about abdominal history (e.g., ulcers, gallbladder issues, appendicitis, colitis, hernia).

  • Medications:

    • List current medications.

  • Lifestyle Factors:

    • Review of alcohol, drug, cigarette use, diet, and exercise habits.

  • Nutritional Status:

    • Assessment concerning intake in the past 24-48 hours.

  • Bowel and Bladder Habits:

COMMON SYMPTOMS

  • Indigestion

  • Anorexia

  • Nausea

  • Vomiting/Hematemesis

  • Abdominal Pain

  • Dysphagia (difficulty swallowing)

  • Odynophagia (painful swallowing)

  • Changes in bowel function:

    • Constipation

    • Diarrhea

  • Jaundice/Icterus

  • Urinary/Renal symptoms:

    • Incontinence

    • Kidney/Flank pain

ABDOMINAL PAIN - SUBJECTIVE

  • Visceral Pain:

    • Occurs when hollow organs are distended, stretched, or contract forcefully.

    • Described as gnawing, burning, cramping, or aching.

  • Parietal Pain:

    • Results from inflammation of the peritoneum.

    • Described as steady, aching, or sharp, especially with movement.

  • Referred Pain:

    • Occurs in distant sites innervated at similar spinal levels as the disordered structure.

ASSESSMENT PREP - OBJECTIVE DATA

  • Prepare for abdominal assessment by:

    • Exposing abdomen for full visibility.

    • Ensuring the patient has emptied bowel or bladder prior before assessment.

    • Placing the patient in a supine position.

    • Examining painful areas last to reduce discomfort.

    • Utilizing relaxation techniques to aid patient comfort.

INSPECTION

  • Assessing Contour, Shape, and Movement:

    • Observing from a standing position across the abdomen.

    • Shape should ideally be flat or rounded; protuberance or distention indicates abnormality.

  • Symmetry:

    • Look for bulging, masses, asymmetry, or signs of ascites (fluid accumulation).

  • Umbilicus:

    • Should be midline; look for hernias, everted appearances during pregnancy.

  • Skin Observations:

    • The skin should be smooth and even; watch for scarring, jaundice, or localized redness (indicating inflammation).

  • Pulsation/Movement:

    • Observe for aortic pulsations, respiratory movement, visible peristalsis (which may indicate obstruction).

  • General Demeanor:

    • Assess if the patient appears relaxed (absence of guarding), slow, and even respirations versus tensed knees or grimacing.

  • Sample Examination of Urine, Emesis, and Stool:

AUSCULTATION

  • Utilize diaphragm of the stethoscope, beginning assessment in the RLQ:

    • Normal Bowel Sounds:

    • High-pitched, gurgling sounds (5-30 times/minute).

    • Hyperactive Bowel Sounds:

    • Occur more than 30 gurgles per minute.

    • Hypoactive/Absent Bowel Sounds:

    • Less than 5-30 gurgles per minute requires auscultation for a full 5 minutes per quadrant to confirm absence.

  • Vascular Sounds - Using Bell:

    • Listen for any bruits, hums, or friction rubs.

PERCUSSION

  • Purpose:

    • To determine organ size and tenderness and detect fluid, air, or masses within the abdomen.

  • Kidney Percussion:

    • Blunt percussion at the costovertebral angle (CVA); pain may indicate kidney infection or stones.

  • Normal Sounds:

    • Tympany should be present over most of the abdomen indicating gas.

  • Dullness Sounds:

    • Dullness may indicate presence of organs, masses, or fluid (expected over the liver in RUQ).

    • Percuss painful areas last to assess for discomfort.

PALPATION

  • Technique:

    • Light palpation: depress about 1 cm, lift fingers, and move clockwise.

    • Deep palpation: depress about 4-6 cm, moving clockwise.

  • Assessment of Masses:

    • Observe location, size, shape, consistency, surface (smooth or nodular), mobility, and tenderness.

  • Liver Palpation:

    • Position the left hand under the patient's back under the 11th/12th ribs, right hand in RUQ alongside midline and apply deep pressure while asking the patient to take a deep breath. Normally feel the edge of the liver touching fingertips during inhalation. If palpated 1-2 cm below ribs, liver is considered enlarged.

  • COPD Considerations:

    • COPD may displace the liver lower due to lung distention.

  • Spleen Palpation:

    • Must be enlarged 3 times its size to be palpable.

  • Bladder Palpation:

    • The bladder can be palpated if it is full or enlarged.

ABNORMAL FINDINGS: PAIN ON PALPATION

  • Tenderness:

    • Note tenderness during light and deep palpation; this can signify peritoneal inflammation or spontaneous infection in the area of pain.

  • Common Pain Sites:

    • Appendicitis:

    • Pain begins at umbilicus, later moving to RLQ (McBurney's point) with rebound tenderness.

    • Ruptured Stomach Ulcer or Diverticulum in LLQ.

    • Cholecystitis in RUQ:

    • Murphy's sign involves hooking your thumb under the right costal margin and asking the patient to take a deep breath; sharp tenderness and a sudden stop in inspiration indicate a positive sign.

    • Cystitis over symphysis pubis.

    • UTI or Inflammation over the bladder.

ABNORMAL FINDINGS: APPENDICITIS

  • McBurney's Point:

    • Located two-thirds the distance from the navel to the right anterior superior iliac spine; tenderness maximal in cases of acute appendicitis.

  • Symptoms:

    • Possible findings include low-grade fever, constipation or diarrhea, nausea, and vomiting.

  • Diagnosis:

    • Physical exam findings may include rebound tenderness, Rovsing's sign, psoas sign, and obturator sign.

    • Laboratory studies may involve WBC count, CT scan, and ultrasound for confirmation.

ABNORMAL FINDINGS: ASCITES

  • Definition:

    • Accumulation of fluid in the abdomen; the fluid shifts with gravity, resulting in dullness to percussion in the lowest point of the abdomen based on the patient’s position.

  • Causes:

    • Conditions such as heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.

ABNORMAL FINDINGS: VASCULAR SOUNDS

  • Bruits:

    • Blowing or swooshing sound located at the left and right midclavicular line between the umbilicus and anterior iliac spine, caused by stenosis of the iliac arteries.

  • Venous Hums:

    • Continuous sounds found in the epigastric region and around the umbilicus, indicative of portal hypertension.

  • Friction Rubs:

    • Harsh grating sounds in RUQ and LUQ, indicative of tumors or inflammation of underlying organs.

URGENT ASSESSMENT

  • Life-threatening Symptoms:

    • Symptoms such as severe dehydration with nausea/vomiting

    • Fever with acute abdominal pain

    • Acute abdominal pain typically for over 6 hours requiring evaluation (possible ruptured appendix, abdominal aortic aneurysm, ruptured fallopian tube, ovarian cyst, ectopic pregnancy, or large blood collections potentially leading to hypovolemic shock).

LIFESPAN CONSIDERATIONS: OLDER ADULTS

  • Potential Alterations due to Aging:

    • Poor dentition affecting chewing and digestion.

    • Reduced saliva production and stomach acid lead to altered digestion.

    • Slower motility and peristalsis can cause bloating, distention, and constipation.

    • Liver shrinkage results in decreased medication metabolism, leading to drug sensitivity.

    • Decreased renal function causing reduced medication elimination.