Abdominal Assessment

Clinical Objectives for Abdominal Assessment

• Identify the specific organs located within each of the four abdominal quadrants.

• Identify pertinent topics and questions to review during the abdominal portion of the patient interview.

• Utilize measures and techniques that enhance abdominal wall relaxation for a more accurate examination.

• Apply the correct sequence of examination techniques: Inspection, Auscultation, Percussion, and Palpation (IAPP).

• Interpret clinical findings obtained during the inspection of the abdomen.

• Interpret clinical findings obtained during the auscultation of the abdomen.

• Interpret clinical findings obtained during the percussion of the abdomen.

• Interpret clinical findings obtained during the palpation of the abdomen.

• Incorporate health promotion concepts into the physical assessment of the abdomen.

Patient History and Interviewing for Abdominal Symptoms

• Obtaining a thorough health history is critical, including symptoms of the present illness and past medical history.

• History of Present Illness (HPI): The nurse should address current abdominal, urinary, and bowel elimination symptoms. If symptoms are reported, inquire about:

  • Onset and duration

  • Character

  • Associated symptoms

  • Current medications

  • Home remedies and their effects

• Abdominal Pain Focused Assessment:

  • Onset and duration: Questions include "When did the pain start?", "How long have you been having pain?", and "Is the pain intermittent or persistent?"

  • Character: Ask the patient to describe the pain (e.g., sharp, dull, burning, stabbing, throbbing, colicky, or cramping) and rate it on a scale of $1-10$.

  • Location: Ask "Can you show me where the pain is located?", "Is the pain superficial or deep?", and "Is the pain in one spot, or does it radiate to other areas?"

  • Other: Inquire about home medications like nonsteroidal anti-inflammatory drugs (NSAIDs) or steroids, and what relieves the pain.

• Indigestion Focused Assessment:

  • Onset and duration: Inquire when it started, how long it has lasted, and the timing (morning, night, before/after meals, all day).

  • Character: Can the patient describe the feeling (fullness, heartburn, discomfort, excessive belching, flatulence, loss of appetite, severe pain)?

  • Location: Is it localized or general? Does it radiate to the arms or shoulders?

  • Other: Inquire about relief measures and home medications.

• Nausea and Vomiting Focused Assessment:

  • Onset and duration: Focus on when it started, duration, and if it lasts all day.

  • Appetite and Menstrual History: Ask about appetite changes and the first day of the last menstrual period (LMP).

  • Character of Vomit: Ask for a description (bright red, coffee grounds appearance, bilious, or composed of undigested food).

  • Medications: Ask about steroids, vitamins, or antibiotics.

Focused History: Urinary and Bowel Symptoms

• Urinary Symptoms:

  • Dysuria (painful, burning urination): Inquire about location (suprapubic, distal urethra), character, frequency/volume changes, water consumption, fever, recent surgery, or catheterization.

  • Urinary Frequency: Note changes in volume or pattern, association with dysuria/hematuria/incontinence/nocturia, and changes in the stream (dribbling).

  • Urinary Incontinence: Track frequency, character (constant, intermittent, dribbling), and triggers (coughing, laughing, exercise, menopause).

  • Hematuria (blood in urine): Determine the character (color, timing in stream) and check for ingestion of red dyes (food coloring or laxatives with phenolphthalein).

• Bowel Elimination Symptoms:

  • Diarrhea: Track onset, frequency, character, relationship to food intake, and associated symptoms like fever, chills, weight loss, or fecal incontinence.

  • Constipation: Note stool character, diet changes (fiber intake), food allergies, activity level changes, and pain/cramping.

  • Fecal Incontinence: Note stool characteristics, timing relative to meals, and number of daily episodes.

  • Jaundice (yellow discoloration of skin/sclera): Caused by greater than normal amounts of bilirubin diglucuronide. Inquire about stool and urine color, abdominal pain, drug use, and exposure to hepatitis.

Medical, Surgical, and Family History

• Medical/Surgical History: Document history of hepatitis, cirrhosis, blood transfusions, abdominal surgeries (including bariatric), urinary/bladder/kidney infections, kidney or gallbladder disease, cystic fibrosis, Hirschsprung’s disease, colorectal/ovarian/endometrial cancer, and GI disorders (peptic ulcer, polyps, IBD, IBS, pancreatitis, intestinal obstruction, hyperlipidemia).

• Family History: Inquire about colorectal cancer and familial colorectal cancer syndromes, gallbladder/kidney disease, malabsorption syndrome, Celiac disease, Hirschsprung’s disease (aganglionic megacolon), Familial Mediterranean fever (periodic peritonitis), and hepatitis.

• Personal/Social History:

  • Nutrition: intake, allergies, weight changes, supplements, fluid intake.

  • Sexual history and last menstrual period (LMP).

  • Alcohol, drug, and tobacco use (frequency, type, amount).

  • Travel history and exposure to infectious diseases.

  • Trauma, abuse (physical, sexual, domestic), and psychological well-being/stressful events.

Anatomy: Abdominal Quadrants and Regions

• Right Upper Quadrant (RUQ): Liver, gallbladder, duodenum, head of pancreas, right adrenal gland, portion of right kidney, hepatic flexure of colon, ascending and transverse colon.

• Right Lower Quadrant (RLQ): Right kidney, cecum, appendix, portion of ascending colon, bladder, ovary and salpinx, uterus, right spermatic cord, right ureter.

• Left Upper Quadrant (LUQ): Left lobe of liver, spleen, stomach, body of pancreas, left adrenal gland, portion of left kidney, splenic flexure of colon, transverse and descending colon.

• Left Lower Quadrant (LLQ): Portion of left kidney, sigmoid colon, descending colon, bladder, ovary and salpinx, uterus, left spermatic cord, left ureter.

• Nine Abdominal Regions:

  • Epigastrium: Pancreas.

  • Umbilical: Small intestine.

  • Hypogastric: Bladder, uterus.

  • Right Hypochondriac: Liver, gallbladder.

  • Left Hypochondriac: Spleen.

  • Right Lumbar: Ascending colon.

  • Left Lumbar: Descending colon.

  • Right Inguinal: Ovary, ureter, appendix.

  • Left Inguinal: Ovary, ureter.

Examination Sequence and Inspection

• Sequence: Inspection, Auscultation, Percussion, Palpation. Percussion and palpation are done last to avoid altering bowel sounds.

• Inspection Elements:

  • Skin color, venous return patterns, lesions, scars, tautness, and striae.

  • Surface structures and umbilicus (position, inflammation, bulging).

  • Contour: Abdominal profile from rib margin to pubis (flat, rounded, scaphoid).

  • Symmetry: Checked while seated and standing.

  • Movement: Surface motion, abdominal landmarks, and venous patterns.

Auscultation and Percussion Techniques

• Auscultation:

  • Use the diaphragm for bowel sounds (character and frequency).

  • Use the diaphragm for friction rubs over the liver and spleen (high-pitched grating sounds).

  • Use the bell for vascular sounds: bruits (over aorta, renal, iliac, femoral arteries) and venous hums.

• Percussion:

  • Used to assess organ size/density (liver, spleen, kidneys, gastric bubble), ascites (fluid), distention (air), or masses.

  • Predominant sound expected: Tympany.

  • Dullness: Found over organs, solid masses, or a distended bladder.

  • Liver span: Determined by percussing upper ($5^{th}$ or $6^{th}$ intercostal space) and lower (costal margin) borders. Normal span is $6-12\,cm$.

  • Spleen: Dullness from $6^{th}$ to $10^{th}$ rib.

  • Kidney tenderness: Assessed via percussion over the lower back (flank/CVA).

Palpation Techniques

• Light Palpation: Standing on the patient's right side, the nurse depresses the abdominal wall $1\,cm$ using a light, circular motion with the palmar surfaces of the fingers. Assesses skin texture, superficial masses, tenderness, and muscle rigidity.

• Moderate Palpation: Uses moderate pressure to determine if the abdomen is soft or rigid and locate tenderness.

• Deep Palpation: Often reserved for advanced practice. Uses a bimanual technique (top hand exerts pressure, bottom hand concentrates on sensation). Used to delineate abdominal organs from pathologic masses.

• Specific Organ Palpation:

  • Umbilicus: Check for incomplete umbilical ring or soft center.

  • Liver: Palpate the edge as the diaphragm pushes it down; it should be firm, smooth, and even.

  • Spleen: Palpate below the left costal margin while the patient takes a deep breath. Repeated with patient on their right side with flexed knees.

  • Kidneys: One hand on flank, the other at costal margin; palpate deeply as the patient exhales.

  • Bladder: Palpate the suprapubic area for distention.

  • Aorta: Palpate left of midline for pulsation. In thin patients, one hand (thumb and fingers) may suffice.

Specialized Clinical Signs and Tests

• Ascites Assessment:

  • Shifting Dullness: Mark borders of tympany/dullness while supine, then repeat while the patient is on their side. Gravity shifts fluid to the dependent side.

  • Fluid Wave: Assistant presses hand edge on vertical midline; examiner strikes one side of the abdomen and feels for the impulse on the other side.

• Appendicitis Scoring Tools:

  • Alvarado Score: Evaluates pain migration, anorexia, nausea/vomiting, RLQ tenderness, rebound pain, temperature, leukocytosis, and left shift.

  • Pediatric Appendicitis Score: Focuses on pain with cough/hopping and RLQ rebound tenderness.

  • Ohmann Score: Uses age, history, physical exam, and laboratory findings.

• Abdominal Diagnostic Signs Table:

  • Aaron: Pain in heart/stomach on palpation of McBurney’s point.

  • Ballance: Fixed dullness in left flank; right flank dullness disappears with position change.

  • Blumberg: Rebound tenderness.

  • Cullen: Ecchymosis around the umbilicus.

  • Dance: Absence of bowel sounds in the RLQ.

  • Grey Turner: Ecchymosis of the flanks.

  • Kehr: Pain radiating to the left shoulder.

  • Markle: Pain triggered by rising on toes and dropping to heels (jarring).

  • McBurney: Rebound tenderness/sharp pain at McBurney’s point.

  • Romberg-Howship: Pain down the medial thigh to the knee.

  • Murphy: Abrupt cessation of inspiration when gallbladder is palpated.

  • Rovsing: RLQ pain intensified by LLQ palpation.

• Additional Procedures:

  • Iliopsoas Muscle Test: Patient raises right leg against resistance or extends it while on their left side. Pain indicates irritation/appendicitis.

  • Obturator Muscle Test: Supine patient flexes right leg to $90$ degrees at hip/knee and rotates medially/laterally. Pain in hypogastric region indicates muscle irritation, ruptured appendix, or pelvic mass.

  • Ballottement: Pushing towards an organ at a $90$-degree angle to see if a mass floats upward.

Expected vs. Abnormal Findings

• Normal Findings:

  • Inspection: Symmetric, flat/rounded/scaphoid contour. Fine venous network. Smooth motion with respiration. Pulsations in upper midline for thin adults.

  • Auscultation: $5-35$ irregular clicks/gurgles per minute. Borborygmi with hunger. No vascular sounds (bruits/hums).

  • Percussion: Predominant tympany. Liver span $6-12\,cm$.

  • Palpation: Soft, nontender. Spleen and gallbladder not usually palpable.

• Age-Related Variations:

  • Infants/Children: Protruding, dome-shaped abdomen until age $3$; respirations are abdominal. Umbilical cord should have $2$ arteries and $1$ vein. Peristalsis every $10-30\,seconds$. Liver edge palpable $1-3\,cm$ below costal margin; spleen palpable $1-2\,cm$ after birth.

  • Older Adults: Thinned abdominal wall, decreased muscle mass, and muscle tone leading to rounded contour. Decreased intestinal motility leads to diminished bowel sounds and constipation. Liver size decreases starting at age $50$. Aortic aneurysms are more easily palpable.

• Abnormal Findings:

  • Inspection: Jaundice, cyanosis, glistening/taut skin, striae, distention, or peristaltic ripples.

  • Auscultation: High-pitched tinkling (obstruction), absent sounds (after $5$ minutes), or bruits.

  • Palpation: Liver border > $2-3\,cm$ below costal margin, palpable spleen, or prominent lateral aortic pulsations (aneurysm risk).

Documentation Standards

• Subjective Data: Include pain, travel, GI history, immunization status (especially Hepatitis A and B), and nutritional habits.

• Objective Data: Document findings like epigastric distention, tenderness, masses, jaundice, and vascular sounds.

• Pediatric Findings: Document specific abnormalities like sausage-shaped masses in upper quadrants (intussusception), peristaltic waves (pyloric stenosis), or splenomegaly (biliary atresia).